Provider Demographics
NPI:1942218755
Name:WELLINGTON, REBECCA R (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
Last Name:WELLINGTON
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 1:2900 S TELEPHONE RD
Mailing Address - Street 2:STE. 250
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2968
Mailing Address - Country:US
Mailing Address - Phone:810-280-3297
Mailing Address - Fax:
Practice Address - Street 1:2900 S TELEPHONE RD
Practice Address - Street 2:STE. 250
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2968
Practice Address - Country:US
Practice Address - Phone:405-237-7507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004125363A00000X
OK2125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRW004125OtherSTATE LISC