Provider Demographics
NPI:1750547048
Name:DETRICK, RACHEL A (PA)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:A
Last Name:DETRICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:A
Other - Last Name:ALCORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 7549
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0549
Mailing Address - Country:US
Mailing Address - Phone:757-686-3515
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:4092 FOXWOOD DR
Practice Address - Street 2:STE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5225
Practice Address - Country:US
Practice Address - Phone:757-467-4200
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002722363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MC10973Medicare PIN