Provider Demographics
NPI:1952528838
Name:MOORE, REBEKAH GRIFFIN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:GRIFFIN
Last Name:MOORE
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 1:1957 CLIFFWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1631
Mailing Address - Country:US
Mailing Address - Phone:419-571-2288
Mailing Address - Fax:419-526-8617
Practice Address - Street 1:1750 W 4TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-1770
Practice Address - Country:US
Practice Address - Phone:419-526-8444
Practice Address - Fax:419-529-8617
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-001308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50-001308OtherSTATE LICENSE