Provider Demographics
NPI:1558665877
Name:STILLWAGON, ROBERT B (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:STILLWAGON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6015
Mailing Address - Country:US
Mailing Address - Phone:559-713-6806
Mailing Address - Fax:559-713-6809
Practice Address - Street 1:392 SIERRA ST
Practice Address - Street 2:
Practice Address - City:KINGSBURG
Practice Address - State:CA
Practice Address - Zip Code:93631
Practice Address - Country:US
Practice Address - Phone:559-869-4736
Practice Address - Fax:559-419-5791
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAES161ZMedicare PIN