Provider Demographics
NPI:1225027436
Name:MOLINE, STEPHANIE ROSE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSE
Last Name:MOLINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ROSE
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3868
Mailing Address - Country:US
Mailing Address - Phone:509-228-1000
Mailing Address - Fax:509-252-9300
Practice Address - Street 1:601 S SHERMAN ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1311
Practice Address - Country:US
Practice Address - Phone:509-228-1000
Practice Address - Fax:509-252-9300
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000417182086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7631MOOtherASURIS NW HEALTH
WA8322315Medicaid
000010140846OtherBLUE SHIELD OF IDAHO
7744005OtherAETNA
ID806453700Medicaid
KS665OtherBLUE CROSS OF IDAHO
WA0164026OtherLABOR & INDUSTRIES
910000395OtherRAILROAD MEDICARE
7631MOOtherASURIS NW HEALTH
ID806453700Medicaid