Basic Information
| Provider Information | |||||||||
| NPI: | 1265474472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 NORTH MAIN | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703652000 | ||||||||
| FaxNumber: | 3607386377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/17/2014 | ||||||||
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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 | 207P00000X | OP00002055 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | E-6639 | AR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1771RO | 01 | WA | BSWA | OTHER | 8448532 | 05 | WA | MEDICAID | 0207213 | 01 | WA | LIWA | OTHER | 1153RO | 01 | WA | BSWA | OTHER | 0207212 | 01 | WA | LIWA | OTHER | 85490 | 01 | AR BLUE CROSS | OTHER |