Provider Demographics
NPI:1003257478
Name:ROBINSON, DAVE (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 BOND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3503
Mailing Address - Country:US
Mailing Address - Phone:208-701-0277
Mailing Address - Fax:208-701-0294
Practice Address - Street 1:1236 BOND AVE STE B
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-701-0277
Practice Address - Fax:208-701-0294
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1376363A00000X
WAOA60492886207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
335109OtherL&I
WA2039543Medicaid
8934345Medicare PIN