Basic Information
| Provider Information | |||||||||
| NPI: | 1215955398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7634271243 | ||||||||
| Practice Location | |||||||||
| Address1: | 6043 HUDSON RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519258200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10006 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42873700 | 05 | WI | MEDICAID | 1045342 | 01 | MN | PREFERRED ONE | OTHER | 135410C029 | 01 | MN | UCARE | OTHER | 477445100 | 05 | MN | MEDICAID | HP54882 | 01 | MN | HEALTHPARTNERS | OTHER | 121502 | 01 | MN | MEDICA | OTHER | 2378486 | 01 | MN | AMERICA'S PPO | OTHER | 625T5WI | 01 | MN | BCBS OF MN | OTHER |