Basic Information
| Provider Information | |||||||||
| NPI: | 1376949388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URIBE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETROS | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1161 21ST AVE S | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372320011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153225000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10506A MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138531300 | ||||||||
| FaxNumber: | 5134514118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2014 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085005277 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 50.004540 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0462231 | 05 | OH | MEDICAID |