Provider Demographics
NPI:1265618110
Name:WORMUTH, ROBERT WILLIAM I (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WORMUTH
Suffix:I
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 1:927 49TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2923
Mailing Address - Country:US
Mailing Address - Phone:718-283-7400
Mailing Address - Fax:718-283-6199
Practice Address - Street 1:927 49TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2923
Practice Address - Country:US
Practice Address - Phone:718-283-7400
Practice Address - Fax:718-283-6199
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004713-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical