Provider Demographics
NPI:1255437893
Name:STANDERFORD, ROBERT M (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:STANDERFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 HANKS ST
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5404
Mailing Address - Country:US
Mailing Address - Phone:936-637-0778
Mailing Address - Fax:
Practice Address - Street 1:1105 W FRANK AVE
Practice Address - Street 2:STE. 290
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3303
Practice Address - Country:US
Practice Address - Phone:936-699-5040
Practice Address - Fax:936-699-5039
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03586363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX048869Medicare UPIN