Provider Demographics
NPI:1609475326
Name:WHEALEN, REBECCA A (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:WHEALEN
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 1:1566 LEMOINE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5635
Mailing Address - Country:US
Mailing Address - Phone:122-877-2112
Mailing Address - Fax:212-287-7210
Practice Address - Street 1:1566 LEMOINE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5635
Practice Address - Country:US
Practice Address - Phone:122-877-2112
Practice Address - Fax:212-287-7210
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
WV363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical