Basic Information
| Provider Information | |||||||||
| NPI: | 1548226640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTROCK | ||||||||
| FirstName: | BECKY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 324 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511020324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122795830 | ||||||||
| FaxNumber: | 7122795883 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 NORTH RERICK AVE | ||||||||
| Address2: | |||||||||
| City: | PRIMGHAR | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7129572310 | ||||||||
| FaxNumber: | 7129570504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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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 | 363AM0700X | 000647 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 22177 | 01 | IA | SIOUX VALLEY HEALTH PLAN | OTHER |