Provider Demographics
NPI:1063091007
Name:GARRETT, REBECCA R (PA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
Last Name:GARRETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 WESTERN BRANCH BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5260
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:2088 S INDEPENDENCE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-4790
Practice Address - Country:US
Practice Address - Phone:757-275-9331
Practice Address - Fax:757-416-7656
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110008123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program