Provider Demographics
NPI:1629008222
Name:MITCHELL, ROBERT R (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:MITCHELL
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 1:229 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2640
Mailing Address - Country:US
Mailing Address - Phone:509-522-0133
Mailing Address - Fax:
Practice Address - Street 1:9915 SANDIFUR PKWY
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8941
Practice Address - Country:US
Practice Address - Phone:509-546-2222
Practice Address - Fax:509-546-2202
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8147043Medicaid
WAPA10003461OtherPA-C LICENSE
WA8147043Medicaid