Provider Demographics
NPI:1508851486
Name:SWANSON, ROBERT ENOCH (CRNP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ENOCH
Last Name:SWANSON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:MILLPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35576-2522
Mailing Address - Country:US
Mailing Address - Phone:205-662-5784
Mailing Address - Fax:205-662-5786
Practice Address - Street 1:13530 HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:MILLPORT
Practice Address - State:AL
Practice Address - Zip Code:35576-2522
Practice Address - Country:US
Practice Address - Phone:205-662-5784
Practice Address - Fax:205-662-5786
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-060045363LF0000X
MSR629014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL541003936Medicaid
AL515-20836OtherBCBSAL
ALP16068Medicare UPIN
AL01-3936Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER