Provider Demographics
NPI:1972551695
Name:REBECK, KEVIN F (PA C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:F
Last Name:REBECK
Suffix:
Gender:M
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 1:397 LITTLE NECK RD STE 120
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-5774
Mailing Address - Country:US
Mailing Address - Phone:757-395-1600
Mailing Address - Fax:757-961-9359
Practice Address - Street 1:397 LITTLE NECK RD STE 120
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-5774
Practice Address - Country:US
Practice Address - Phone:757-395-1600
Practice Address - Fax:757-961-9359
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139178OtherBCBS
VAP00387578OtherRR MEDICARE
VA10014277POtherSENTARA
VA1972551695Medicaid
VA10014277POtherOPTIMA
R23439Medicare UPIN
VA1972551695Medicaid