Provider Demographics
NPI:1619083243
Name:STUCKE, REBECCA M (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:STUCKE
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 1:79 AUSTIN RD
Mailing Address - Street 2:
Mailing Address - City:SWANTON
Mailing Address - State:VT
Mailing Address - Zip Code:05488-8466
Mailing Address - Country:US
Mailing Address - Phone:802-527-9876
Mailing Address - Fax:
Practice Address - Street 1:92 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1728
Practice Address - Country:US
Practice Address - Phone:802-524-4046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0300769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant