Active NPI
Charles Wayne Robertson, PTA
- Physical Therapy Assistant
- Poplar Bluff, MO
National Provider Identifier
1174772495
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 2000161109
- Practice address
- 2725 N Westwood Blvd
Poplar Bluff, MO 63901-2346 - Phone
- (573) 778-9348
- Fax
- (573) 778-3463
- NPI assigned
- Sep 10, 2008
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 2000161109 | MO | Primary |
Addresses
Primary practice location
2725 N Westwood Blvd
Poplar Bluff, MO 63901-2346
Mailing address
2725 N Westwood Blvd
Poplar Bluff, MO 63901-2346
Phone (573) 778-9348
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2000161109 | MO | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1221004800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1221004800000",
"number": "1174772495",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2725 N WESTWOOD BLVD",
"city": "POPLAR BLUFF",
"state": "MO",
"postal_code": "639012346",
"telephone_number": "573-778-9348",
"fax_number": "573-778-3463"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2725 N WESTWOOD BLVD",
"city": "POPLAR BLUFF",
"state": "MO",
"postal_code": "639012346",
"telephone_number": "573-778-9348",
"fax_number": "573-778-3463"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROBERTSON",
"first_name": "CHARLES",
"middle_name": "WAYNE",
"credential": "PTA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2008-09-10",
"last_updated": "2008-09-10",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "MO",
"license": "2000161109",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Poplar Bluff, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 10, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.