Provider Demographics
NPI:1700343258
Name:BOSTON, REBECCA CORTEZ
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CORTEZ
Last Name:BOSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 S PATTERSON DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7246
Mailing Address - Country:US
Mailing Address - Phone:405-361-4969
Mailing Address - Fax:
Practice Address - Street 1:1213 S PATTERSON DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-7246
Practice Address - Country:US
Practice Address - Phone:405-361-4969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKN082499442OtherDRIVER'S LICENSE