Provider Demographics
NPI:1538039870
Name:JOHN, REBECCA SARA (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SARA
Last Name:JOHN
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 1:570 FULTON ST APT 6H
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-5467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-11
Last Update Date:2025-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034901363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty