Provider Demographics
NPI:1467447847
Name:KLOTZ, ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KLOTZ
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 1:13 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-3026
Mailing Address - Country:US
Mailing Address - Phone:207-772-4203
Mailing Address - Fax:
Practice Address - Street 1:1375 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2118
Practice Address - Country:US
Practice Address - Phone:207-772-4203
Practice Address - Fax:207-780-1055
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA76363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KLAP1590Medicare ID - Type Unspecified