Provider Demographics
NPI:1144219429
Name:STAHLECKER, ROSE (PAC)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:STAHLECKER
Suffix:
Gender:F
Credentials:PAC
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 50
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-0050
Mailing Address - Country:US
Mailing Address - Phone:701-742-3267
Mailing Address - Fax:701-742-3201
Practice Address - Street 1:420 SOUTH 7TH STREET
Practice Address - Street 2:
Practice Address - City:OAKES
Practice Address - State:ND
Practice Address - Zip Code:58474-2024
Practice Address - Country:US
Practice Address - Phone:701-742-3267
Practice Address - Fax:701-742-3201
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18134OtherBLUE SHIELD
ND28585OtherBLUE SHIELD
ND18133OtherBLUE SHIELD
ND19187OtherBLUE SHIELD
ND19188OtherBLUE SHIELD
ND28586OtherBLUE SHIELD
ND25977OtherBLUE SHIELD
970009835OtherTRAVELERS MEDICARE
ND18134OtherBLUE SHIELD
ND28585OtherBLUE SHIELD
R02391Medicare UPIN
ND970009835Medicare Oscar/Certification
NDN18133Medicare PIN
ND970009835Medicare PIN