Provider Demographics
NPI:1548226640
Name:WITTROCK, BECKY J (PA)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:J
Last Name:WITTROCK
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:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0324
Mailing Address - Country:US
Mailing Address - Phone:712-279-5830
Mailing Address - Fax:712-279-5883
Practice Address - Street 1:240 NORTH RERICK AVE
Practice Address - Street 2:
Practice Address - City:PRIMGHAR
Practice Address - State:IA
Practice Address - Zip Code:51245
Practice Address - Country:US
Practice Address - Phone:712-957-2310
Practice Address - Fax:712-957-0504
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000647363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22177OtherSIOUX VALLEY HEALTH PLAN
IA22177OtherSIOUX VALLEY HEALTH PLAN
IAI7256Medicare PIN