Provider Demographics
NPI:1215955398
Name:WILSON, REBEKAH JOY (PA)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:JOY
Last Name:WILSON
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 1:3833 COON RAPIDS BLVD NW
Mailing Address - Street 2:STE 100
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2577
Mailing Address - Country:US
Mailing Address - Phone:763-427-8320
Mailing Address - Fax:763-427-1243
Practice Address - Street 1:6043 HUDSON RD STE 220
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1033
Practice Address - Country:US
Practice Address - Phone:651-925-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42873700Medicaid
MN1045342OtherPREFERRED ONE
MN135410C029OtherUCARE
MN477445100Medicaid
MNHP54882OtherHEALTHPARTNERS
MN121502OtherMEDICA
MN2378486OtherAMERICA'S PPO
MN625T5WIOtherBCBS OF MN
MNHP54882OtherHEALTHPARTNERS
MN625T5WIOtherBCBS OF MN