Provider Demographics
NPI:1295926608
Name:HOLBERG, REBECCA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:HOLBERG
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 1:84 COPPER MINE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2118
Mailing Address - Country:US
Mailing Address - Phone:617-838-5319
Mailing Address - Fax:
Practice Address - Street 1:55 NYE RD
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1281
Practice Address - Country:US
Practice Address - Phone:860-633-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1718363AM0700X
CT001423363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical