Provider Demographics
NPI:1023532280
Name:ROBERSON, NATHAN KELLY (NP-C)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:KELLY
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 N OAK ST STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5913
Mailing Address - Country:US
Mailing Address - Phone:229-241-8925
Mailing Address - Fax:
Practice Address - Street 1:4340 KINGS WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6921
Practice Address - Country:US
Practice Address - Phone:229-333-9736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214086363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner