Provider Demographics
NPI:1891782579
Name:BACON, ROBYN (PA)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:
Last Name:BACON
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 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:10 DAVOL SQ
Practice Address - Street 2:SUITE 400
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4754
Practice Address - Country:US
Practice Address - Phone:401-421-4000
Practice Address - Fax:401-272-1456
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI27960-0OtherBCBS OF RI
SC411838OtherBLUE CHIP
RI9003736Medicaid
RIQ27501Medicare UPIN