Provider Demographics
NPI:1497257745
Name:VAN METER, ROBERT EDWARD
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:VAN METER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9774
Mailing Address - Country:US
Mailing Address - Phone:815-842-2828
Mailing Address - Fax:
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-842-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005294363A00000X
IL085.006605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant