Provider Demographics
NPI:1972148708
Name:LAND, ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LAND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 BROAD ST S
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31001-4305
Mailing Address - Country:US
Mailing Address - Phone:229-467-3209
Mailing Address - Fax:
Practice Address - Street 1:417 BROAD ST S
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31001-4305
Practice Address - Country:US
Practice Address - Phone:229-467-3209
Practice Address - Fax:229-467-3212
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11017363A00000X
SC3418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11017OtherMEDICAL LICENSE