Healthcare Provider Details

I. General information

NPI: 1295830586
Provider Name (Legal Business Name): IVAN L ROBINSON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 30TH ST
MOUNT RAINIER MD
20712-1751
US

IV. Provider business mailing address

4201 30TH ST
MT RAINER MD
20712
US

V. Phone/Fax

Practice location:
  • Phone: 202-652-0536
  • Fax: 202-536-4369
Mailing address:
  • Phone: 202-652-0536
  • Fax: 202-536-4369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR197474
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: