Provider Demographics
NPI:1871711929
Name:MAXON, ROBIN (AUD)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:MAXON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2515
Mailing Address - Country:US
Mailing Address - Phone:541-605-0550
Mailing Address - Fax:541-605-0552
Practice Address - Street 1:1613 5TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2515
Practice Address - Country:US
Practice Address - Phone:541-605-0550
Practice Address - Fax:541-605-0552
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21908231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028030000OtherBLUE CROSS BLUE SHIELD
OR640003829OtherRAILROAD MEDICARE
OR158836Medicaid
ORI056301OtherPACIFIC SOURCE
OR640003829OtherRAILROAD MEDICARE