Provider Demographics
NPI:1518159870
Name:GREEN, REBECCA L (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:RUNGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2500 CANTERBURY DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2247
Mailing Address - Country:US
Mailing Address - Phone:785-261-7599
Mailing Address - Fax:
Practice Address - Street 1:2500 CANTERBURY DR
Practice Address - Street 2:SUITE 112
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2247
Practice Address - Country:US
Practice Address - Phone:785-261-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007028966363AS0400X
KS15-01210363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
39905011OtherBCBS TRICARE
KSP00467266OtherRR MEDICARE-KS
MOP00467259OtherRR MEDICARE-MO
KSP00467266OtherRR MEDICARE-KS
39905011OtherBCBS TRICARE