Provider Demographics
NPI:1588898035
Name:WILLIAMSON, STEVEN STENBERG (PAC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:STENBERG
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 WOODWINDS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2522
Mailing Address - Country:US
Mailing Address - Phone:651-968-5201
Mailing Address - Fax:
Practice Address - Street 1:2090 WOODWINDS DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2522
Practice Address - Country:US
Practice Address - Phone:651-968-5201
Practice Address - Fax:651-968-5201
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2473-23363AS0400X
MN10630363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970004200Medicare PIN
WI1588898035Medicaid
MN1588898035Medicaid
WI56080-0045/491280044Medicare PIN