Provider Demographics
NPI:1992743215
Name:STAHLBERG, BILL (PA-C)
Entity type:Individual
Prefix:
First Name:BILL
Middle Name:
Last Name:STAHLBERG
Suffix:
Gender:M
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 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2320 FREEWAY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5445
Practice Address - Country:US
Practice Address - Phone:360-814-6800
Practice Address - Fax:360-814-6953
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01128363AS0400X
IDPA-6052363AS0400X
WAPA61078913363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1992743215Medicaid
ORP00346032Medicare PIN
OR135107Medicare PIN
ID20003089Medicare PIN
ID1992743215Medicaid