Provider Demographics
NPI:1023045689
Name:ROBERTS, BENJAMIN JOEL (CRNA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOEL
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 1:10628 PARK RD
Mailing Address - Street 2:ANESTHESIA DEPARTMENT
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8407
Mailing Address - Country:US
Mailing Address - Phone:704-667-1971
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8407
Practice Address - Country:US
Practice Address - Phone:704-667-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC185344367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAN638Medicaid
NC8052584Medicaid
NC2610924Medicare PIN