Provider Demographics
NPI:1083702666
Name:CHILDRESS, ROBIN H (PA)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:H
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:H
Other - Last Name:HARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:LAHEY HOSPITAL & MEDICAL CENTER
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8460
Mailing Address - Fax:781-744-5261
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:LAHEY HOSPITAL & MEDICAL CENTER
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8460
Practice Address - Fax:781-744-5261
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14595363AM0700X
MAPA161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS39318Medicare UPIN
CAWPA14595BMedicare PIN