Provider Demographics
NPI:1265704266
Name:BRAITH, STEPHANIE M (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:BRAITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4920 S 30TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1656
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:
Practice Address - Street 1:4920 S 30TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1590
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-734-3990
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12424363A00000X
NE1634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant