Provider Demographics
NPI:1417951096
Name:DETTMAR, ROBYN (PA)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:
Last Name:DETTMAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MONTE VISTA AVE
Mailing Address - Street 2:190
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-2962
Mailing Address - Country:US
Mailing Address - Phone:909-865-9977
Mailing Address - Fax:909-946-0122
Practice Address - Street 1:1601 MONTE VISTA AVE
Practice Address - Street 2:190
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-2962
Practice Address - Country:US
Practice Address - Phone:909-865-9977
Practice Address - Fax:909-946-0122
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P76432Medicare UPIN