Provider Demographics
NPI:1124326475
Name:WINTER, STEPHANIE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WINTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E CORRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7524
Mailing Address - Country:US
Mailing Address - Phone:907-260-5455
Mailing Address - Fax:907-714-3111
Practice Address - Street 1:108 E CORRAL AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7524
Practice Address - Country:US
Practice Address - Phone:907-260-5455
Practice Address - Fax:907-714-3111
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT653363A00000X
AK2213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0529Medicaid
AK1124326475OtherNPI
AKK164679Medicare UPIN