Provider Demographics
NPI:1053887208
Name:STEELE, ROBERT LEE IV (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:STEELE
Suffix:IV
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:404 GLENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-2425
Mailing Address - Country:US
Mailing Address - Phone:662-471-1805
Mailing Address - Fax:
Practice Address - Street 1:1757 HIGHWAY 178 W STE A
Practice Address - Street 2:
Practice Address - City:MYRTLE
Practice Address - State:MS
Practice Address - Zip Code:38650-9233
Practice Address - Country:US
Practice Address - Phone:662-988-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00396207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01950520Medicaid