Provider Demographics
NPI:1497105605
Name:JACOB, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:JACOB
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 1:180 KENNEDY MEMORIAL DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4541
Mailing Address - Country:US
Mailing Address - Phone:207-873-3753
Mailing Address - Fax:
Practice Address - Street 1:180 KENNEDY MEMORIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4541
Practice Address - Country:US
Practice Address - Phone:207-873-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant