Provider Demographics
NPI:1467425504
Name:EGOLF, ROBEN L (ASSISTANT)
Entity Type:Individual
Prefix:PROF
First Name:ROBEN
Middle Name:L
Last Name:EGOLF
Suffix:
Gender:M
Credentials:ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROUTE 56
Mailing Address - Street 2:BOX 123
Mailing Address - City:FISHERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15539
Mailing Address - Country:US
Mailing Address - Phone:814-839-4152
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 56
Practice Address - Street 2:BOX 123
Practice Address - City:FISHERTOWN
Practice Address - State:PA
Practice Address - Zip Code:15539
Practice Address - Country:US
Practice Address - Phone:814-839-4152
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002235L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS28283Medicare UPIN
PA046711PEEMedicare ID - Type Unspecified