Provider Demographics
NPI:1861438590
Name:HODGE, ROBERT A (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:HODGE
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:PO BOX 843257
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3257
Mailing Address - Country:US
Mailing Address - Phone:910-715-4111
Mailing Address - Fax:910-715-4101
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-4111
Practice Address - Fax:910-715-4101
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03646363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0191260OtherSTATE L&I
WA8348690Medicaid
WA8939674OtherCRIME VICTIMS
S67591Medicare UPIN
WA0191260OtherSTATE L&I
WA8939674OtherCRIME VICTIMS