Provider Demographics
NPI:1417020769
Name:ROBERTS, MEGAN SHANE (NP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:SHANE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:SHANE
Other - Last Name:ROBERTIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4425 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-3662
Mailing Address - Country:US
Mailing Address - Phone:912-355-6615
Mailing Address - Fax:912-351-0645
Practice Address - Street 1:4425 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-3662
Practice Address - Country:US
Practice Address - Phone:912-355-6615
Practice Address - Fax:912-351-0645
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR213006-2363L00000X
VA0024167195363L00000X
GARN263330363L00000X
MDAC001046363L00000X
SC20667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417020769Medicaid
VA012494W25Medicare PIN
VA1417020769Medicaid