Provider Demographics
NPI:1861985657
Name:BLACK, ROBERT LEE III (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:BLACK
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-5266
Mailing Address - Fax:814-373-5269
Practice Address - Street 1:640 ALDEN ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2348
Practice Address - Country:US
Practice Address - Phone:814-373-5255
Practice Address - Fax:814-373-5259
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2025-04-01
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant