Provider Demographics
NPI:1588651129
Name:NOUN, STEFANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:NOUN
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 1:1405 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1422
Mailing Address - Country:US
Mailing Address - Phone:641-236-1991
Mailing Address - Fax:
Practice Address - Street 1:122 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1829
Practice Address - Country:US
Practice Address - Phone:641-236-4323
Practice Address - Fax:641-236-3411
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ56936Medicare UPIN