Provider Demographics
NPI:1962431387
Name:FOX, ROBERT E (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:FOX
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 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:386-287-0410
Mailing Address - Fax:386-287-0411
Practice Address - Street 1:404 NW HALL OF FAME DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4833
Practice Address - Country:US
Practice Address - Phone:386-287-0410
Practice Address - Fax:386-287-0411
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1873363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290022000Medicaid
FLY09QZOtherBLUE SHIELD OF FLORIDA
FLY09QZOtherBLUE SHIELD OF FLORIDA
FLS67582Medicare UPIN
FLY09QZOtherBLUE SHIELD OF FLORIDA