Provider Demographics
NPI:1124491808
Name:FENTON, ROBERT (FNP-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FENTON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13027 STATE HIGHWAY 155 S
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-6548
Mailing Address - Country:US
Mailing Address - Phone:903-839-1000
Mailing Address - Fax:903-630-8048
Practice Address - Street 1:13027 STATE HIGHWAY 155 S
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6548
Practice Address - Country:US
Practice Address - Phone:903-839-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX728909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner