Provider Demographics
NPI:1740519628
Name:PORTWOOD, ROBERT NEAL (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:NEAL
Last Name:PORTWOOD
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 1:5306 COUNTY ROAD 7360
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-7316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3364
Practice Address - Country:US
Practice Address - Phone:806-775-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant