Provider Demographics
NPI:1144240615
Name:PESTLE, REBECCA L (PAC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PESTLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 SW RANGE DR
Practice Address - Street 2:
Practice Address - City:WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394-9634
Practice Address - Country:US
Practice Address - Phone:541-563-3197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23236363AM0700X
ORPA213386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000097163OtherBCBS PIN
MT4308684OtherMDCD PIN
MT000097163OtherBCBS PIN
MT000085267Medicare PIN
MTP00332416Medicare PIN
MT000085266Medicare PIN
MT1153260003Medicare PIN