Basic Information
| Provider Information | |||||||||
| NPI: | 1801852017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ILGEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 HALL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109681200 | ||||||||
| FaxNumber: | 4109683005 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 HALL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109681200 | ||||||||
| FaxNumber: | 4109683005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 04/29/2014 | ||||||||
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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 | C0000562 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.