Healthcare Provider Details

I. General information

NPI: 1366836207
Provider Name (Legal Business Name): REBEKIAH PEARSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER DR
ADA OK
74820-3439
US

IV. Provider business mailing address

1921 STONECIPHER DR
ADA OK
74820-3439
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-3980
  • Fax:
Mailing address:
  • Phone: 580-436-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3094
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: