Provider Demographics
NPI:1316117500
Name:SMULLEN, STEPHANIE R (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:SMULLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:RUNKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2845 GREENBRIER RD STE 240
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8280
Mailing Address - Fax:920-288-8285
Practice Address - Street 1:2845 GREENBRIER RD STE 240
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8280
Practice Address - Fax:920-288-8285
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316117500Medicaid
WI1316117500Medicaid
WI076500297Medicare PIN
WI714600066Medicare PIN