Provider Demographics
NPI:1629497334
Name:MCGARY, REBECCA DEZOUCHE (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DEZOUCHE
Last Name:MCGARY
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5420
Mailing Address - Fax:704-384-5424
Practice Address - Street 1:1901 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1101
Practice Address - Country:US
Practice Address - Phone:704-384-5420
Practice Address - Fax:704-384-5424
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007146363A00000X
NC0010-07198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP01321563OtherRAILROAD MEDICARE
GA003146262AMedicaid
SC1885PAMedicaid
GA202I975725Medicare PIN