Provider Demographics
NPI:1790750628
Name:REALE, ROBYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:MARIE
Last Name:REALE
Suffix:
Gender:F
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:KENNER ARMY HEALTH CLINIC
Mailing Address - Street 2:700 24 TH STREET
Mailing Address - City:FORT GREGG-ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9057
Mailing Address - Fax:804-734-9289
Practice Address - Street 1:700 24TH STREET
Practice Address - Street 2:KENNER ARMY HEALTH CLINIC
Practice Address - City:FORT GREGG- ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9057
Practice Address - Fax:804-734-9289
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1790750628Medicaid
NC2759955AMedicare ID - Type Unspecified
NCQ01841Medicare UPIN