Basic Information
| Provider Information | |||||||||
| NPI: | 1497989404 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SURPRENANT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 GRESHAM DR | ||||||||
| Address2: | # 5B | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883198 | ||||||||
| FaxNumber: | 7573884242 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 S MANNING BLVD | ||||||||
| Address2: | 7422 GAB LOVE | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185251693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2009 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.