Provider Demographics
NPI:1871590661
Name:ROBERTSON, KARYN F (PA)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:F
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7165 E UNIVERSITY DR STE 187
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-6415
Mailing Address - Country:US
Mailing Address - Phone:480-668-5000
Mailing Address - Fax:480-428-8593
Practice Address - Street 1:7165 E UNIVERSITY DR STE 183
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-6415
Practice Address - Country:US
Practice Address - Phone:480-668-5000
Practice Address - Fax:480-668-5065
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002551363A00000X, 363AS0400X
AZ1339363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109160Medicaid
Z72820Medicare UPIN
NY02617307Medicaid