Basic Information
| Provider Information | |||||||||
| NPI: | 1255324919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EWALD | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSN, CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 590 RADIO HILL RD | ||||||||
| Address2: | SUITE 1 MEDICAL ARTS BUILDING | ||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767838183 | ||||||||
| FaxNumber: | 2767829267 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 RADIO HILL RD | ||||||||
| Address2: | SUITE 1 MEDICAL ARTS BUILDING | ||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767838183 | ||||||||
| FaxNumber: | 2767829267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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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 | 363LP0200X | 0017137762 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0017137762 | 01 | VA | VIRGINIA LIS. | OTHER |