Provider Demographics
NPI:1568559029
Name:SEBASTIAN, ROBIN D (MD, FAAFP)
Entity Type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:D
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:MD, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2713
Mailing Address - Country:US
Mailing Address - Phone:208-365-6004
Mailing Address - Fax:208-365-3589
Practice Address - Street 1:1102 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2713
Practice Address - Country:US
Practice Address - Phone:208-365-6004
Practice Address - Fax:208-365-3589
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188205207Q00000X
IDM10681207Q00000X
PAMD435743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010174773OtherREGENCE BLUE SHIELD OF IDAHO
ORMD125789OtherOREGON LICENSE NUMBER
IDM10681OtherIDAHO LICENSE NUMBER
ID808440301Medicaid
ID808440302Medicaid
ID808440300Medicaid
ID808440300Medicaid
FS1174212OtherDEA NUMBER
ORR149451Medicare PIN
ID1373849Medicare PIN
ID000010174773OtherREGENCE BLUE SHIELD OF IDAHO
ID1373847Medicare PIN
ORMD125789OtherOREGON LICENSE NUMBER