Provider Demographics
NPI:1790025443
Name:GORANSON, REBECCA D (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:GORANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:DAUBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 800022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-0022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MERCADO ST STE 202
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7307
Practice Address - Country:US
Practice Address - Phone:970-764-9400
Practice Address - Fax:970-764-9449
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1902363AS0400X
SC363A00000X
COPA.0005954363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant