Provider Demographics
NPI:1205468725
Name:CARL, STEPHANIE ELIZABETH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:CARL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W BROADWAY ST STE 320
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4003
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-80026363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical