Provider Demographics
NPI:1447710207
Name:YOUNGBLOOD, ROBERT (NP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HEMLOCK STREET MSC #104
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2168
Mailing Address - Country:US
Mailing Address - Phone:478-633-7550
Mailing Address - Fax:
Practice Address - Street 1:821 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2343
Practice Address - Country:US
Practice Address - Phone:478-633-7550
Practice Address - Fax:478-633-3235
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239843363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner