MEDICARE: MRS. REBECCA ANN PELKOLA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA17779	CA
2	363A00000X	Physician Assistant	PA900	NV
3	363A00000X	Physician Assistant	11014	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CC7589	OTHER	NV	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245221860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA ANN PELKOLA PA-C

Provider Business Mailing Address
First Line	:	913 EAST 26TH STREET
Second Line	:	TWIN CITIES SPINE CENTER PIPER BUILDING, SUITE 600
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4515
Country	:	US
Telephone Number	:	612-775-6200
Fax Number	:	612-775-6222

Provider Business Practice Location Address
First Line	:	913 EAST 26TH STREET
Second Line	:	TWIN CITIES SPINE CENTER PIPER BUILDING, SUITE 600
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4515
Country	:	US
Telephone Number	:	612-775-6200
Fax Number	:	612-775-6222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	03/11/2021

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