Provider Demographics
NPI:1053321513
Name:SPRINGER, ROBERTO (PA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:SPRINGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 CHESTNUT LN RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6214
Mailing Address - Country:US
Mailing Address - Phone:706-372-6102
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700700-A
Practice Address - Street 2:78 MDG/XXX
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:706-372-6102
Practice Address - Fax:706-372-6102
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003709363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001136BMedicaid
R88961Medicare UPIN
GA97WCDPNMedicare ID - Type Unspecified