Provider Demographics
NPI:1053720490
Name:MICHAELS, REBECCA WAGNER (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:WAGNER
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 W MAIN ST APT 119
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3389
Mailing Address - Country:US
Mailing Address - Phone:757-642-3860
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN ROAD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-1910
Practice Address - Country:US
Practice Address - Phone:919-681-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006278363A00000X
NC0010-11827363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant