Provider Demographics
NPI:1316122781
Name:DILLER, REBECCA KAY (PA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:KAY
Last Name:DILLER
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 FAULK ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5086
Practice Address - Country:US
Practice Address - Phone:980-442-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14239207R00000X, 363A00000X
PAMA053317363AM0700X
VA0110-007924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149619OtherMEDICARE GROUP PTAN
MD945LOtherMEDICARE GROUP PTAN
MD256561ZDDBMedicare PIN
MD945LOtherMEDICARE GROUP PTAN