Provider Demographics
NPI:1497989404
Name:SURPRENANT, ROBERT R (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:SURPRENANT
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 1:600 GRESHAM DR
Mailing Address - Street 2:# 5B
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-3198
Mailing Address - Fax:757-388-4242
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:7422 GAB LOVE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical