Provider Demographics
NPI:1578884847
Name:STAFFORD, REBECCA L (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:PA-C
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 912882
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2882
Mailing Address - Country:US
Mailing Address - Phone:866-765-0909
Mailing Address - Fax:855-856-8520
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-8222
Practice Address - Fax:605-755-4203
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1578884847Medicaid
ND1471560Medicaid
WY1578884847Medicaid
SD1578884847Medicaid