Provider Demographics
NPI:1629378641
Name:VARGO, ROBIN L (PA)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:L
Last Name:VARGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6736
Mailing Address - Country:US
Mailing Address - Phone:512-294-1170
Mailing Address - Fax:
Practice Address - Street 1:690 BARNES BLVD
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98438-1303
Practice Address - Country:US
Practice Address - Phone:253-982-0328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014421363AM0700X
TXPA07611363A00000X
WAPA 60404079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02997217Medicaid