Provider Demographics
NPI:1235107285
Name:STEPHANIE, JOSEPH WALTER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:WALTER
Last Name:STEPHANIE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55837 E HIGHWAY 55
Mailing Address - Street 2:BOX 121
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-9394
Mailing Address - Country:US
Mailing Address - Phone:320-243-3908
Mailing Address - Fax:
Practice Address - Street 1:55837 E HIGHWAY 55
Practice Address - Street 2:BOX 121
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-9394
Practice Address - Country:US
Practice Address - Phone:320-243-3908
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 063332-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR 063332-5OtherNURSING LICENSE