Provider Demographics
NPI:1164709705
Name:ROBINSON, DETRA CHAMBERS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DETRA
Middle Name:CHAMBERS
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DETRA
Other - Middle Name:MONTEIZ YVONNE
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PL STE 130
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3671
Practice Address - Country:US
Practice Address - Phone:704-384-1950
Practice Address - Fax:704-384-1955
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant