Provider Demographics
NPI:1245434620
Name:MACOMBER, ROBERT LEWIS (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEWIS
Last Name:MACOMBER
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 1:1734 COUNTY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-8486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant