Provider Demographics
NPI:1417911066
Name:IRVING, REBECCA LYNNE (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:IRVING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNNE
Other - Last Name:VANDER SLOOT - VANDERMOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8000 SR 64 E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212
Mailing Address - Country:US
Mailing Address - Phone:941-792-1404
Mailing Address - Fax:941-761-0712
Practice Address - Street 1:8000 SR 64 E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212
Practice Address - Country:US
Practice Address - Phone:941-792-1404
Practice Address - Fax:941-761-0712
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1E8STOtherFL BCBS
MIN88490001Medicare PIN