Basic Information
| Provider Information | |||||||||
| NPI: | 1962431387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOX | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85006 CREWS RD | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320341556 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1865 LIME ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043212422 | ||||||||
| FaxNumber: | 9043212434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1873 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA1873 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | Y09QZ | 01 | FL | BLUE SHIELD OF FLORIDA | OTHER | 290022000 | 05 | FL | MEDICAID |