Provider Demographics
NPI:1003392713
Name:VANWIE, REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:VANWIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1474
Mailing Address - Country:US
Mailing Address - Phone:518-489-2663
Mailing Address - Fax:518-689-3881
Practice Address - Street 1:500 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2414
Practice Address - Country:US
Practice Address - Phone:518-489-2663
Practice Address - Fax:518-689-3881
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05343802Medicaid
NY022250OtherNY LICENSE