Provider Demographics
NPI:1730117078
Name:SEGARRA, ROBERT (PAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SEGARRA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-3616
Mailing Address - Country:US
Mailing Address - Phone:727-623-6399
Mailing Address - Fax:
Practice Address - Street 1:812 W INDIAN RIVER BLVD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-3429
Practice Address - Country:US
Practice Address - Phone:386-426-1411
Practice Address - Fax:376-426-0457
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL:PA9101755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0038ROtherMEDICARE PTAN
FLP79397Medicare UPIN