Provider Demographics
NPI:1720273295
Name:MOORE, REBECCA IVRY (PAC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:IVRY
Last Name:MOORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:IVRY
Other - Last Name:MOORE PAZDERNIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 3262
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-3262
Mailing Address - Country:US
Mailing Address - Phone:907-224-4916
Mailing Address - Fax:907-224-5870
Practice Address - Street 1:201 3RD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-224-4916
Practice Address - Fax:907-224-5870
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19315363A00000X
AKPAD A 830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19315Medicaid
CAWPA19315AMedicare PIN