Provider Demographics
NPI:1871791582
Name:ROUNDY, ROBERT BENJAMIN (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BENJAMIN
Last Name:ROUNDY
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 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-494-6700
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:1806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2473
Practice Address - Country:US
Practice Address - Phone:509-452-4520
Practice Address - Fax:509-452-5224
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0258889OtherLABOR AND INDUSTRIES
WA8487837Medicaid
WAAB38059Medicare Oscar/Certification
WAG8888805Medicare PIN