Provider Demographics
NPI:1477700573
Name:WESTERGARD, REBECCA A (PA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:A
Last Name:WESTERGARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-522-0747
Mailing Address - Fax:208-522-9641
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-522-0747
Practice Address - Fax:208-522-9641
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-751363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant