Provider Demographics
NPI:1275994048
Name:IDZAKOVICH, ROBERT GERARD (FNP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GERARD
Last Name:IDZAKOVICH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2770
Mailing Address - Country:US
Mailing Address - Phone:740-464-8125
Mailing Address - Fax:
Practice Address - Street 1:2511 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2770
Practice Address - Country:US
Practice Address - Phone:740-464-8125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN391062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily