Provider Demographics
NPI:1538115753
Name:RICK, REBEKAH RUTH (PA)
Entity Type:Individual
Prefix:MS
First Name:REBEKAH
Middle Name:RUTH
Last Name:RICK
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 1:10 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1820
Mailing Address - Country:US
Mailing Address - Phone:320-634-5157
Mailing Address - Fax:320-634-2253
Practice Address - Street 1:10 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1820
Practice Address - Country:US
Practice Address - Phone:320-634-5157
Practice Address - Fax:320-634-2253
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 06720363A00000X
MN9825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN717613900Medicaid
MNHP42449OtherHEALTH PARTNERS
MN490R7RIOtherBLUE CROSS HOSPITAL
MNNA9091043263OtherPREFERRED ONE
MN970002213Medicare Oscar/Certification