Provider Demographics
NPI:1992732374
Name:ROBERTS, AUDREY M (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
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 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-689-9107
Practice Address - Fax:316-689-9354
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1707OtherPHS
KS100405OtherHPK
KS168637OtherCOVENTRY
KS024978OtherBCBS
KS12149397OtherMULTIPLAN
KS1707OtherPHS
KS100405OtherHPK