Basic Information
| Provider Information | |||||||||
| NPI: | 1073993440 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RIDEOUT | ||||||||
| FirstName: | REBECCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 VARNUM AVE | ||||||||
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| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376000 | ||||||||
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| Address1: | 295 VARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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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 | 363A00000X | PA6433 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1073993440 | 01 | NPI NUMBER | OTHER |