Basic Information
| Provider Information | |||||||||
| NPI: | 1255987079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POPP | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LORENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POPP | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | LORENE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3515 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922511 | ||||||||
| FaxNumber: | 6207866298 | ||||||||
| Practice Location | |||||||||
| Address1: | 3515 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922511 | ||||||||
| FaxNumber: | 6207866298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2019 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | M72390 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 53-78974-102 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 13-79843-102 | KS | N | Nursing Service Providers | Registered Nurse |
No ID Information.