Provider Demographics
NPI:1003572041
Name:HADDAD, REBECCA (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HADDAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BECCA
Other - Middle Name:
Other - Last Name:HADDAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:12657 N KENOSHA LN APT J303
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-7477
Mailing Address - Country:US
Mailing Address - Phone:412-841-3114
Mailing Address - Fax:
Practice Address - Street 1:2426 N MERRITT CREEK LOOP STE A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4961
Practice Address - Country:US
Practice Address - Phone:208-819-2183
Practice Address - Fax:208-209-6063
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2271971363A00000X
WAPA70037722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4919OtherTN BOARD OF MEDICAL EXAMINERS
TNMH7058298OtherDEA