Provider Demographics
NPI:1013030949
Name:SMITH, REBECCA J (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-7190
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:9209 PHOENIX VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4280
Practice Address - Country:US
Practice Address - Phone:636-561-4630
Practice Address - Fax:636-561-4610
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2021-09-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2006013856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant