Healthcare Provider Details

I. General information

NPI: 1538115753
Provider Name (Legal Business Name): REBEKAH RUTH RICK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 4TH AVE SE
GLENWOOD MN
56334-1820
US

IV. Provider business mailing address

10 4TH AVE SE
GLENWOOD MN
56334-1820
US

V. Phone/Fax

Practice location:
  • Phone: 320-634-5157
  • Fax: 320-634-2253
Mailing address:
  • Phone: 320-634-5157
  • Fax: 320-634-2253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 06720
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9825
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: