Provider Demographics
NPI:1710160353
Name:MCDONALD, STEPHANIE PIKE (PA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:PIKE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:PIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:13005 COVEY CIR
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-6934
Mailing Address - Country:US
Mailing Address - Phone:209-532-0126
Mailing Address - Fax:209-532-2950
Practice Address - Street 1:680 GUZZI LN STE 105
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-532-0126
Practice Address - Fax:209-532-2950
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000970A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000556059OtherANTHEM
IN000000556059OtherANTHEM
IN062110H6Medicare PIN