Provider Demographics
NPI:1366958761
Name:ROBERTS, MATTHEW OWEN (CRNA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:OWEN
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 1:9705 ANCHOR DR
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-5032
Mailing Address - Country:US
Mailing Address - Phone:205-602-6470
Mailing Address - Fax:
Practice Address - Street 1:809 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2029
Practice Address - Country:US
Practice Address - Phone:205-759-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-124775367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse