Provider Demographics
NPI:1386942381
Name:MCCLOUGH, REBECCA (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MCCLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5970 FAIRVIEW RD STE 430
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3117
Mailing Address - Country:US
Mailing Address - Phone:704-503-9884
Mailing Address - Fax:704-870-3968
Practice Address - Street 1:5970 FAIRVIEW RD STE 430
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3117
Practice Address - Country:US
Practice Address - Phone:704-503-9884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2450363A00000X
NC0010-02744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2501PAMedicaid
NC8101588Medicaid
NC2762677Medicare PIN
NC8101588Medicaid