Provider Demographics
NPI:1659827939
Name:BAE, REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1714 E HUNDRED RD
Mailing Address - Street 2:STE 104
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-3310
Mailing Address - Country:US
Mailing Address - Phone:804-681-0566
Mailing Address - Fax:804-410-4619
Practice Address - Street 1:2369 STAPLES MILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2909
Practice Address - Country:US
Practice Address - Phone:804-285-8206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110-005460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant