Provider Demographics
NPI:1245634609
Name:DELOACH, ROBERT (NP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DELOACH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-992-0420
Mailing Address - Fax:760-416-1651
Practice Address - Street 1:10925 BLUFFSIDE DR
Practice Address - Street 2:#419
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3310
Practice Address - Country:US
Practice Address - Phone:310-922-5889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001345363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily