Provider Demographics
NPI:1366772261
Name:ROBERTS, RICHARD A (CRNA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 952270
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75395-0001
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:1000 PINE ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5100
Practice Address - Country:US
Practice Address - Phone:903-427-3851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX805949367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8065UBOtherBCBS
TX2080578001Medicaid
AR1366772261OtherBCBS
TX2080578002Medicaid
TXTXB125307Medicare PIN