Provider Demographics
NPI:1720215700
Name:WICKENHEISER, REBEKAH RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:RENEE
Last Name:WICKENHEISER
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:5125 JONESTOWN RD STE 105
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-2987
Practice Address - Country:US
Practice Address - Phone:717-943-1566
Practice Address - Fax:717-943-1566
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054001363A00000X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00801522Medicare PIN
PA327955YUNMMedicare PIN
PA233913YEBKMedicare PIN
PA169304FLTMedicare PIN