Provider Demographics
NPI:1033801147
Name:ISHAM, STEPHEN LEO ROELOF JOZEF (MEDICAL STUDENT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEO ROELOF JOZEF
Last Name:ISHAM
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7352 S GREENSFERRY RD
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-7165
Mailing Address - Country:US
Mailing Address - Phone:208-819-3441
Mailing Address - Fax:
Practice Address - Street 1:19555 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6813
Practice Address - Country:US
Practice Address - Phone:623-572-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program