Provider Demographics
NPI:1003839424
Name:STANEK, CHRISTINE ANN (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:STANEK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ANN
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3524 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-646-3505
Mailing Address - Fax:541-646-3553
Practice Address - Street 1:2859 STATE STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-282-6505
Practice Address - Fax:541-282-6520
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450119NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120982Medicare UPIN
ORQ39971Medicare UPIN