Provider Demographics
NPI:1790769594
Name:FLORES, REBECCA L (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:FLORES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:GRIMSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:271 CAREW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2377
Mailing Address - Country:US
Mailing Address - Phone:413-748-9349
Mailing Address - Fax:413-452-6080
Practice Address - Street 1:1221 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5311
Practice Address - Country:US
Practice Address - Phone:413-748-9349
Practice Address - Fax:413-452-6080
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2546Medicare PIN
Q58543Medicare UPIN