Provider Demographics
NPI:1457329542
Name:WOOD, ROBERT ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:WOOD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:509-990-9640
Mailing Address - Fax:907-459-3500
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-459-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003794363A00000X
AK139988363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017647OtherREGENCE BLUE SHIELD OF ID
WA970019578OtherRR MEDICARE
WA8929877OtherCRIME VICTIMS
WAWO4266OtherASURIS NW HEALTH
WA379109600OtherOWCP
ID003783300Medicaid
WA149074OtherDEPT OF LABOR & INDUSTRI
WA15388OtherGROUP HEALTH NW
WA8387359Medicaid
IDKQ506OtherBLUE CROSS OF IDAHO
S33438Medicare UPIN
WA8387359Medicaid