Provider Demographics
NPI:1649821646
Name:POUTRE, ROBERT MONROE (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MONROE
Last Name:POUTRE
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:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0863
Mailing Address - Country:US
Mailing Address - Phone:082-638-5972
Mailing Address - Fax:
Practice Address - Street 1:606 N THIRD AVE STE 201
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1689
Practice Address - Country:US
Practice Address - Phone:082-638-5972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13178363A00000X
IDPA-2045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant