Basic Information
| Provider Information | |||||||||
| NPI: | 1134428923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERSON | ||||||||
| FirstName: | TYRONE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | AGPCNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6439 GARNERS FERRY | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037764000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6439 GARNERS FERRY | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037764000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2011 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 69630 | SC | N | Nursing Service Providers | Registered Nurse | Emergency | 164W00000X | PR27111 | SC | N | Nursing Service Providers | Licensed Practical Nurse | 363L00000X | 19344 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.