Provider Demographics
NPI:1326382508
Name:BAKKESTUEN, REBECCA OLSON (PAC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:OLSON
Last Name:BAKKESTUEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 GREENS DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4612
Mailing Address - Country:US
Mailing Address - Phone:919-256-3576
Mailing Address - Fax:919-787-4870
Practice Address - Street 1:3200 BLUE RIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8087
Practice Address - Country:US
Practice Address - Phone:919-781-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03833363AM0700X, 363A00000X
SCPA1925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC9553BMedicare PIN