Provider Demographics
NPI:1053680819
Name:RICHARD, REBECCA L (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:RICHARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:CASTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:36 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-3408
Mailing Address - Country:US
Mailing Address - Phone:860-885-0666
Mailing Address - Fax:860-885-1158
Practice Address - Street 1:36 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3408
Practice Address - Country:US
Practice Address - Phone:860-885-0666
Practice Address - Fax:860-885-1158
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002676OtherPHYSICIAN ASSISTANT LICENSE