Provider Demographics
NPI:1285864769
Name:MATHIS, REBEKA LEANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:REBEKA
Middle Name:LEANN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:LEANN
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1719 RUSSELL PKWY
Mailing Address - Street 2:BLDG. 300
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5763
Mailing Address - Country:US
Mailing Address - Phone:478-923-0106
Mailing Address - Fax:
Practice Address - Street 1:1719 RUSSELL PKWY
Practice Address - Street 2:BLDG. 300
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5763
Practice Address - Country:US
Practice Address - Phone:478-923-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant