Provider Demographics
NPI:1497934897
Name:WAHL, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:WAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N BINKLEY ST
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7523
Mailing Address - Country:US
Mailing Address - Phone:907-262-9341
Mailing Address - Fax:907-262-1545
Practice Address - Street 1:265 N BINKLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7523
Practice Address - Country:US
Practice Address - Phone:907-262-9341
Practice Address - Fax:907-262-1545
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA 3683207P00000X, 207Q00000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD 3683Medicaid
G32027Medicare UPIN
AKMD 3683Medicaid