Provider Demographics
NPI:1184669384
Name:EMERSON, BECKY (PA-C)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:EMERSON
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 1:1301 S CLIFF AVE
Mailing Address - Street 2:STE 506
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1005
Mailing Address - Country:US
Mailing Address - Phone:605-335-0844
Mailing Address - Fax:605-977-1715
Practice Address - Street 1:1301 S CLIFF AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1005
Practice Address - Country:US
Practice Address - Phone:605-335-0844
Practice Address - Fax:605-977-1715
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD575363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6827623Medicaid
SD6827625Medicaid
SDS106113Medicare PIN
SD6827623Medicaid