Provider Demographics
NPI:1285736611
Name:HENNING, ROBERT A (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:HENNING
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 1:232 HIDDEN BAY DR
Mailing Address - Street 2:#302
Mailing Address - City:OSPREY
Mailing Address - State:FL
Mailing Address - Zip Code:34229-9176
Mailing Address - Country:US
Mailing Address - Phone:941-966-3924
Mailing Address - Fax:
Practice Address - Street 1:25097 OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3903
Practice Address - Country:US
Practice Address - Phone:941-764-5858
Practice Address - Fax:941-639-3805
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102276363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2580ZMedicare ID - Type Unspecified
FLQ16096Medicare UPIN