Provider Demographics
NPI:1588894612
Name:LONGSHORE, REBEKAH KRISTINE
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:KRISTINE
Last Name:LONGSHORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12319 N MOPAC EXPY STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12313 NORTH MOPAC EXPRESSWAY
Practice Address - Street 2:#200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-973-8276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18892363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health