Provider Demographics
NPI:1568486694
Name:BROADAWAY, REBECCA (RPA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BROADAWAY
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:KANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:GLENS FALLS HOSPITAL ECC
Mailing Address - Street 2:100 PARK ST
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-926-3050
Mailing Address - Fax:518-926-3127
Practice Address - Street 1:GLENS FALLS HOSPITAL ECC
Practice Address - Street 2:100 PARK AVE
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-926-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S72853Medicare UPIN
NYPA0362Medicare ID - Type Unspecified