Provider Demographics
NPI:1952485591
Name:WYATT KILGORE, REBECCA (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WYATT KILGORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:GRUBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-5781
Practice Address - Fax:804-828-5717
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166302363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010129575Medicaid
VA006649M94Medicare ID - Type UnspecifiedC03684
VA010129575Medicaid