Provider Demographics
NPI:1538921721
Name:PROVOST, REBECCA BORDEAUX
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:BORDEAUX
Last Name:PROVOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 PARSONS RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3348
Mailing Address - Country:US
Mailing Address - Phone:854-201-3636
Mailing Address - Fax:854-201-1983
Practice Address - Street 1:204 PARSONS RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3348
Practice Address - Country:US
Practice Address - Phone:854-201-3636
Practice Address - Fax:854-201-1983
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program