Provider Demographics
NPI:1700842721
Name:VAN DOLAH, REBECCA A (MPAS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:VAN DOLAH
Suffix:
Gender:F
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ALICE PECK DAY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2900
Mailing Address - Country:US
Mailing Address - Phone:603-448-3121
Mailing Address - Fax:603-448-7462
Practice Address - Street 1:17 ALICE PECK DAY DR UNIT C
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-2684
Practice Address - Country:US
Practice Address - Phone:603-448-6344
Practice Address - Fax:603-448-3405
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1892255A2300X
CT6026363A00000X
NH0947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer