Provider Demographics
NPI:1063747889
Name:LOONEY, REBECCA ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:LOONEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBEECA
Other - Middle Name:LOONEY
Other - Last Name:OBENZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5712
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1493363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0906PAMedicaid
SCGP3508OtherMEDICAID GROUP ID#
SCAA45137498Medicare PIN