Basic Information
| Provider Information | |||||||||
| NPI: | 1932634706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1806 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094524520 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1806 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094524520 | ||||||||
| FaxNumber: | 5094525224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ML60756123 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60963500 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60963491 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2080268 | 05 | WA | MEDICAID |