Provider Demographics
NPI:1952571184
Name:GILLISPIE, REBECCA LYNNE (PAC)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LYNNE
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNNE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2349
Practice Address - Street 1:1551 E MULLAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9005
Practice Address - Country:US
Practice Address - Phone:208-262-2328
Practice Address - Fax:208-619-5057
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005348363AM0700X
IDPA-832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808532700Medicaid