Provider Demographics
NPI:1861499618
Name:KABAKJIAN, ROBERT SR (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KABAKJIAN
Suffix:SR
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 1:15 EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9198
Mailing Address - Country:US
Mailing Address - Phone:803-408-3277
Mailing Address - Fax:803-408-3299
Practice Address - Street 1:15 EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9198
Practice Address - Country:US
Practice Address - Phone:803-408-3277
Practice Address - Fax:803-408-3277
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06494363A00000X
SCTL606363AM0700X
SCPA606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1551PAMedicaid
TX8L22671Medicare PIN
TXP02027Medicare UPIN
TX8L22670Medicare PIN