Healthcare Provider Details

I. General information

NPI: 1982033395
Provider Name (Legal Business Name): REBECCA D CHURCH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 N OVERLAND AVE
BURLEY ID
83318-3433
US

IV. Provider business mailing address

9040 A JACKSON AVE
JOINT BASE LEWIS MCCHORD WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-6996
  • Fax:
Mailing address:
  • Phone: 253-968-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60491889
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1911
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: