Provider Demographics
NPI:1376949388
Name:URIBE, REBECCA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:URIBE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MARIE
Other - Last Name:PETROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1161 21ST AVE S
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-0011
Mailing Address - Country:US
Mailing Address - Phone:615-322-5000
Mailing Address - Fax:
Practice Address - Street 1:10506A MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-853-1300
Practice Address - Fax:513-451-4118
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005277363A00000X
363AM0700X
OH50.004540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0462231Medicaid