Provider Demographics
NPI:1962560755
Name:ROBERTS, REBECCA (PA-C)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:1255 VISCAYA PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3290
Practice Address - Country:US
Practice Address - Phone:239-574-1988
Practice Address - Fax:239-574-1435
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0F0GOtherFLORIDA BLUE
FLY0F0GOtherFLORIDA BLUE