1578884847 NPI number — REBECCA L STAFFORD PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578884847 NPI number — REBECCA L STAFFORD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAFFORD
Provider First Name:
REBECCA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578884847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 912882
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80291-2882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-765-0909
Provider Business Mailing Address Fax Number:
855-856-8520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 FAIRMONT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57701-7375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-755-8222
Provider Business Practice Location Address Fax Number:
605-755-4203
Provider Enumeration Date:
06/21/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0792 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1578884847 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1471560 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1578884847 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1578884847 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".