Provider Demographics
NPI:1306912464
Name:SPRAGUE, REBECCA (NPC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 J STREET
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5520
Mailing Address - Country:US
Mailing Address - Phone:916-456-0400
Mailing Address - Fax:916-340-0621
Practice Address - Street 1:3835 J STREET
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5520
Practice Address - Country:US
Practice Address - Phone:916-456-0400
Practice Address - Fax:916-340-0621
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11828207NS0135X
CANP11828207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068235Medicaid
CARN314798Medicaid
CAGR006823BMedicaid
CAGR0068230Medicaid
CAGR0068231Medicaid
CAGR0068232Medicaid
CAZZZ47675ZOtherBLUE SHIELD
CAZZZ47676ZOtherBLUE SHIELD
CAGR0068233Medicaid
CAZZZ47673ZOtherBLUE SHIELD
CAZZZ62306ZOtherBLUE SHIELD
CAGR0068231Medicaid
CAZZZ28052ZMedicare PIN
CAZZZ00965ZMedicare PIN
P23069Medicare UPIN
CAZZZ00968ZMedicare PIN
CAGR0068230Medicaid
CAGR006823BMedicaid
CAGR0068233Medicaid