MEDICARE: ROBYN DETTMAR PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085001894	IL

General Provider Information

NPI Number	:	1417951096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBYN DETTMAR PA

Provider Business Mailing Address
First Line	:	1601 MONTE VISTA AVE
Second Line	:	190
City	:	CLAREMONT
State	:	CA
Zip	:	91711-2962
Country	:	US
Telephone Number	:	909-865-9977
Fax Number	:	909-946-0122

Provider Business Practice Location Address
First Line	:	1601 MONTE VISTA AVE
Second Line	:	190
City	:	CLAREMONT
State	:	CA
Zip	:	91711-2962
Country	:	US
Telephone Number	:	909-865-9977
Fax Number	:	909-946-0122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	12/30/2021

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Directions to “ ROBYN DETTMAR PA” Practice Location

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