Provider Demographics
NPI:1447448964
Name:BIRD, REBEKAH J (PA)
Entity type:Individual
Prefix:MISS
First Name:REBEKAH
Middle Name:J
Last Name:BIRD
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:P O BOX 1647
Mailing Address - Street 2:3100 CHANNING WAY
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-1647
Mailing Address - Country:US
Mailing Address - Phone:208-535-4130
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-535-4130
Practice Address - Fax:208-535-4125
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12345OtherALL PENDING