Provider Demographics
NPI:1447573126
Name:PRICE, REBECCA L (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PRICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:560 W MITCHELL ST STE 500
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2277
Mailing Address - Country:US
Mailing Address - Phone:231-487-2100
Mailing Address - Fax:231-487-1909
Practice Address - Street 1:114 RUSH ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2920
Practice Address - Country:US
Practice Address - Phone:231-347-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260468363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447573126Medicaid
MIP12980009OtherMEDICARE ID