Provider Demographics
NPI:1689027427
Name:HAUA, STEPHANIE LAUREN
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:LAUREN
Last Name:HAUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8583 AERO DR
Mailing Address - Street 2:APT. 2088
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6719 ALVARADO RD
Practice Address - Street 2:SUITE 308
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5270
Practice Address - Country:US
Practice Address - Phone:619-265-7912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-17
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA53930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program