Provider Demographics
NPI:1497735195
Name:HOSE, STEPHANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:HOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:KAY
Other - Last Name:KINKEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7719
Mailing Address - Fax:573-635-2156
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7719
Practice Address - Fax:573-635-2156
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111174207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204713408Medicaid
MO070013526OtherRAILROAD MEDICARE
MOCD6059OtherRR GROUP
MO070013526OtherRAILROAD MEDICARE
MO204713408Medicaid