Basic Information
| Provider Information | |||||||||
| NPI: | 1497017073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRBY | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RILEY | ||||||||
| OtherFirstName: | REBEKAH | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 204 PROFESSIONAL CT SE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307017020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066255900 | ||||||||
| FaxNumber: | 7066255906 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 PROFESSIONAL CT SE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307017020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066255900 | ||||||||
| FaxNumber: | 7066255906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2012 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6471 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.