Provider Demographics
NPI:1376563155
Name:BRUGGERS, REBECCA KAY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:KAY
Last Name:BRUGGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:KAY
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:1027 BELLEVUE AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1851
Practice Address - Country:US
Practice Address - Phone:314-645-4600
Practice Address - Fax:314-645-2249
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006020959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097335Medicare PIN
Q38371Medicare UPIN