Provider Demographics
NPI:1578528188
Name:DEDWYLDER, REBEKAH MEADOWS (PA)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:MEADOWS
Last Name:DEDWYLDER
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 1:2901 FRANCES PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-2401
Mailing Address - Country:US
Mailing Address - Phone:901-826-8242
Mailing Address - Fax:
Practice Address - Street 1:2901 FRANCES PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2401
Practice Address - Country:US
Practice Address - Phone:901-826-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ65293Medicare UPIN