Basic Information
| Provider Information | |||||||||
| NPI: | 1538115753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICK | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 4TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563341820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206345157 | ||||||||
| FaxNumber: | 3206342253 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 4TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563341820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206345157 | ||||||||
| FaxNumber: | 3206342253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 06720 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 9825 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 717613900 | 05 | MN | MEDICAID | HP42449 | 01 | MN | HEALTH PARTNERS | OTHER | 490R7RI | 01 | MN | BLUE CROSS HOSPITAL | OTHER | NA9091043263 | 01 | MN | PREFERRED ONE | OTHER |