Provider Demographics
NPI:1295741221
Name:YELKEN, ROBERT LEONARD (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEONARD
Last Name:YELKEN
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:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:GLEN ST MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32040-0606
Mailing Address - Country:US
Mailing Address - Phone:386-755-5044
Mailing Address - Fax:386-755-2518
Practice Address - Street 1:789 W DUVAL ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3811
Practice Address - Country:US
Practice Address - Phone:386-755-1546
Practice Address - Fax:386-755-2283
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290657100Medicaid
FL41384YMedicare ID - Type Unspecified
FL290657100Medicaid