Provider Demographics
NPI:1053858704
Name:COLE, ROBERT (FNP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:CHARLES
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:3545 CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6507
Mailing Address - Country:US
Mailing Address - Phone:928-279-5552
Mailing Address - Fax:
Practice Address - Street 1:3545 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:KING,AN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:US
Practice Address - Phone:928-279-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ161234363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily