Provider Demographics
NPI:1801801337
Name:BOOTH, ROBIN (PA)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-691-8070
Mailing Address - Fax:
Practice Address - Street 1:1301 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7500
Practice Address - Fax:270-417-7509
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S87797Medicare UPIN