Healthcare Provider Details

I. General information

NPI: 1700832326
Provider Name (Legal Business Name): REBECCA ELLEN VEASEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBECCA ELLEN BEVERSDORF PA-C

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 NORTH CONVENT SUITE C
BOURBONNAIS IL
60914-0000
US

IV. Provider business mailing address

1000 REMINGTON BLVD SUITE 100 (ATTN: MELVONNE JONES)
BOLINGBROCK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-5167
  • Fax: 630-914-2469
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001046
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.001046
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: