Provider Demographics
NPI:1346230653
Name:LAGE, STEPHANIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:LAGE
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1400
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:2780 CLEVELAND AVE
Practice Address - Street 2:SUITE 819
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5858
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102148363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9102148OtherLICENSE
FLPA9102148OtherLICENSE
P70051Medicare UPIN