Provider Demographics
NPI:1013944925
Name:DUFFER, ROBERT CONWAY JR (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CONWAY
Last Name:DUFFER
Suffix:JR
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:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1328
Mailing Address - Country:US
Mailing Address - Phone:804-435-8570
Mailing Address - Fax:804-435-8037
Practice Address - Street 1:9891 GENERAL PULLER HWY
Practice Address - Street 2:
Practice Address - City:HARTFIELD
Practice Address - State:VA
Practice Address - Zip Code:23071-3122
Practice Address - Country:US
Practice Address - Phone:804-776-9221
Practice Address - Fax:804-776-7537
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV1034AMedicare PIN
VAP00616663Medicare PIN
VA017651R53Medicare PIN