Provider Demographics
NPI:1265925382
Name:FERGUSON, REBECCA LYNN (PA)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LYNN
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:13419 SPRING GROVE AVENUE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:918-579-5749
Mailing Address - Fax:918-579-5762
Practice Address - Street 1:2021 N MACARTHUR BOULEVARD
Practice Address - Street 2:SUITE 350
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061
Practice Address - Country:US
Practice Address - Phone:918-579-5749
Practice Address - Fax:918-579-5762
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08148363A00000X
OK3145363AM0700X
TXPA12783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical