Provider Demographics
NPI:1205028263
Name:NENTWICH, ROBERT W (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:NENTWICH
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 1:850 N MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1841
Mailing Address - Country:US
Mailing Address - Phone:435-896-9561
Mailing Address - Fax:435-896-9564
Practice Address - Street 1:850 N MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1841
Practice Address - Country:US
Practice Address - Phone:435-896-9561
Practice Address - Fax:435-896-9564
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101800-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant