Provider Demographics
NPI:1437138351
Name:HENRY, ROBERT (PAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24459 SUSSEX HWY
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-4433
Mailing Address - Country:US
Mailing Address - Phone:302-629-3099
Mailing Address - Fax:302-629-6059
Practice Address - Street 1:24459 SUSSEX HWY
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-4433
Practice Address - Country:US
Practice Address - Phone:302-629-3099
Practice Address - Fax:302-629-6059
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1437138351Medicaid
Q05756Medicare UPIN
DE1437138351Medicaid