Provider Demographics
NPI:1558542522
Name:STEDKE, KERRY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ANN
Last Name:STEDKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BELLEFONTAINE AVE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2851
Mailing Address - Country:US
Mailing Address - Phone:419-227-2727
Mailing Address - Fax:
Practice Address - Street 1:1005 BELLEFONTAINE AVE
Practice Address - Street 2:SUITE 175
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2851
Practice Address - Country:US
Practice Address - Phone:419-227-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071002Medicaid