Provider Demographics
NPI:1760716419
Name:DASTRUP, STEPHANIE RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:DASTRUP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 SPANISH RIDGE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1319
Mailing Address - Country:US
Mailing Address - Phone:702-330-3102
Mailing Address - Fax:702-912-4994
Practice Address - Street 1:2880 N TENAYA WAY STE 420
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0642
Practice Address - Country:US
Practice Address - Phone:702-255-2022
Practice Address - Fax:702-255-8810
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1760716419Medicaid
NV1760716419Medicaid