Provider Demographics
NPI:1639339567
Name:TULEY, REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:TULEY
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 1:247 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401
Mailing Address - Country:US
Mailing Address - Phone:715-223-5851
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4102
Practice Address - Country:US
Practice Address - Phone:715-847-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2296-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43020700Medicaid