Provider Demographics
NPI:1043219686
Name:WISHNEV, STEPHANIE A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:WISHNEV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50607
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89016-0607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 S. JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2310
Practice Address - Country:US
Practice Address - Phone:702-739-6467
Practice Address - Fax:702-733-1689
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8168208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002280Medicaid
NV002002280Medicaid
36523Medicare ID - Type Unspecified