=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003572041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA HADDAD PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2021
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2426 N MERRITT CREEK LOOP STE A
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-4961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-819-2183
-----------------------------------------------------
Fax | 208-209-6063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12657 N KENOSHA LN APT J303
-----------------------------------------------------
City | RATHDRUM
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83858-7477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-841-3114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2271971
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA70037722
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------