Provider Demographics
NPI:1174575658
Name:SUSTALA, ROBIN (NP)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:SUSTALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 INDUSTRIAL AVE
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-2901
Mailing Address - Country:US
Mailing Address - Phone:817-270-3132
Mailing Address - Fax:
Practice Address - Street 1:141 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2901
Practice Address - Country:US
Practice Address - Phone:817-270-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP116602363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100310620CMedicaid
KS161454Medicare PIN
KS100310620CMedicaid