Basic Information
| Provider Information | |||||||||
| NPI: | 1295967255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBINSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLER | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1501 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ATLANTIC | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500221936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122432850 | ||||||||
| FaxNumber: | 7122437423 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ATLANTIC | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500221936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122432850 | ||||||||
| FaxNumber: | 7122437423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2009 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 002024 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.