Provider Demographics
NPI:1285730689
Name:NOTTESTAD, STEPHANIE J (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:NOTTESTAD
Suffix:
Gender:F
Credentials:PA
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:701-323-6543
Mailing Address - Fax:
Practice Address - Street 1:414 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4423
Practice Address - Country:US
Practice Address - Phone:701-323-6543
Practice Address - Fax:701-323-6960
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17744Medicare PIN
NDR94846Medicare UPIN