Provider Demographics
NPI:1154618601
Name:PEREZ, REBECCA L (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-4195
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-356-5401
Practice Address - Fax:208-356-3111
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154618601Medicaid
WI1154618601Medicaid
WI450340085Medicare PIN