Provider Demographics
NPI:1376844290
Name:DELOACH, REBECCA SMITH (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SMITH
Last Name:DELOACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ELIZABETH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8614
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:905 VERDAE BLVD STE 204
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4029
Practice Address - Country:US
Practice Address - Phone:864-255-5609
Practice Address - Fax:864-240-5028
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant