Provider Demographics
NPI:1598709248
Name:DEVELLE, ROBERT E (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:DEVELLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 GLENCOE AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6385
Mailing Address - Country:US
Mailing Address - Phone:310-301-2030
Mailing Address - Fax:310-306-5247
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13924363A00000X
NVPA1507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13924OtherMEDICAL LICENSE
NV1598709248Medicaid
NVV107451Medicare PIN