Provider Demographics
NPI:1548402050
Name:MOZENTER TIPPETT, ROBIN L (PA)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:L
Last Name:MOZENTER TIPPETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:L
Other - Last Name:POLINGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7891 TUCKAHOE CT
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2599
Mailing Address - Country:US
Mailing Address - Phone:610-316-6531
Mailing Address - Fax:
Practice Address - Street 1:900 CATON AVE
Practice Address - Street 2:OPERATING ROOM
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:410-368-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000021L363AS0400X
MDC0004006363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical