Provider Demographics
NPI:1114969813
Name:NATYSHOK, STEPHANIE L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:NATYSHOK
Suffix:
Gender:F
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 1:1212 PROFESSIONAL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8002
Mailing Address - Country:US
Mailing Address - Phone:812-401-9030
Mailing Address - Fax:812-401-9033
Practice Address - Street 1:1212 PROFESSIONAL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-8002
Practice Address - Country:US
Practice Address - Phone:812-401-9030
Practice Address - Fax:812-401-9033
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001987363A00000X
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL97008OtherUMWA PROVIDER NUMBER
ILL97008OtherUMWA PROVIDER NUMBER
ILCB3700OtherRAILROAD MEDICARE GROUP
ILP82003Medicare UPIN
ILL97008OtherUMWA PROVIDER NUMBER