Provider Demographics
NPI:1548377518
Name:BOOTH, ROBERT DOUGLAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:BOOTH
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 1:1698 PEACH AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-5216
Mailing Address - Country:US
Mailing Address - Phone:901-830-8826
Mailing Address - Fax:
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-516-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT127045363A00000X
AZ6889363A00000X
ME1666363A00000X
AR399363A00000X
TXPA04555363A00000X, 363AM0700X
TNPA1459363AM0700X
MSPA00081363AM0700X
TN1459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0Medicaid
TN36650572Medicaid
TN36650572Medicare PIN
Q51116Medicare UPIN
8D9162Medicare ID - Type Unspecified