Provider Demographics
NPI:1114968112
Name:STEPHEN, KRISTEN A (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:STEPHEN
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-7190
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1000 STONEWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8386
Practice Address - Country:US
Practice Address - Phone:920-663-7190
Practice Address - Fax:920-684-1439
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061435L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA896012Medicare PIN
PAG45869Medicare UPIN
896012Medicare ID - Type Unspecified
PA896012Medicare PIN