Provider Demographics
NPI:1164933750
Name:OERTEL, STEPHANIE JANE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANE
Last Name:OERTEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-1528
Mailing Address - Country:US
Mailing Address - Phone:203-637-0662
Mailing Address - Fax:
Practice Address - Street 1:1285 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CT
Practice Address - Zip Code:06878
Practice Address - Country:US
Practice Address - Phone:203-637-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03992363A00000X
NY023090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant