Provider Demographics
NPI:1356307664
Name:SUTPHIN, REBECCA L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:L
Last Name:SUTPHIN
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 1:803 CANVAS CT
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584-8844
Mailing Address - Country:US
Mailing Address - Phone:423-741-0519
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05853363A00000X, 363AS0400X
VA0110001067363AS0400X
TN0000000910363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1356307664OtherMEDICAID QMB
VA1356307664OtherUMWA
VA1356307664OtherHUMANA MEDICARE
VA1356307664OtherBLACK LUNG
VA1356307664OtherANTHEM MEDIGAP
VA1356307664OtherAETNA
VAP01041461OtherRAILROAD MEDICARE
VA1356307664OtherOPTIMA HEALTH PLAN
VA1356307664OtherINTOTAL
VA540506332108OtherTRICARE/CHAMPUS
VA1356307664OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA1356307664OtherUMWA