Provider Demographics
NPI:1023130440
Name:WINTERS, CANDACE M (PA)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:M
Last Name:WINTERS
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:PO BOX 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:605-341-7062
Practice Address - Street 1:2201 S DOUGLAS HWY STE 120
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5408
Practice Address - Country:US
Practice Address - Phone:800-446-9556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1477523678Medicaid
SD6829360Medicaid
SD0645OtherLICENSE
SD9248507OtherDAKOTACARE
SD4993240OtherWELLMARK
SDS102377Medicare PIN