Provider Demographics
NPI:1518262542
Name:KEITH, STEPHANIE L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:KEITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:WEATHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2885 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4404
Mailing Address - Country:US
Mailing Address - Phone:414-771-6780
Mailing Address - Fax:414-755-0476
Practice Address - Street 1:2311 N PROSPECT AVE STE 5A
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4445
Practice Address - Country:US
Practice Address - Phone:414-319-3000
Practice Address - Fax:414-319-3097
Is Sole Proprietor?:No
Enumeration Date:2011-01-23
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4291363A00000X, 363AS0400X
OKAPA1969363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant