Basic Information
| Provider Information | |||||||||
| NPI: | 1053606111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 26TH AVE N | ||||||||
| Address2: | |||||||||
| City: | NORTH MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295822106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435139330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 809 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2011 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | AA45 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.