Provider Demographics
NPI:1407823768
Name:PERRY, ROBERT GEORGE (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GEORGE
Last Name:PERRY
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 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN MEDICAL STAFF OFFICE
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2815 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2224
Practice Address - Country:US
Practice Address - Phone:863-284-6900
Practice Address - Fax:863-284-6904
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S69021Medicare UPIN
FLE17782Medicare ID - Type Unspecified
FL292703900Medicaid