Provider Demographics
NPI:1164856886
Name:REBO, CHAD RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:RYAN
Last Name:REBO
Suffix:
Gender:M
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 1:320 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2010
Mailing Address - Country:US
Mailing Address - Phone:406-283-6900
Mailing Address - Fax:406-293-6622
Practice Address - Street 1:340 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1702
Practice Address - Country:US
Practice Address - Phone:801-428-3500
Practice Address - Fax:801-322-2831
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8776901-1206363A00000X
MTMED-PAC-LIC-41920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant