Provider Demographics
NPI:1669521324
Name:EDISS, STEPHAN PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:PAUL
Last Name:EDISS
Suffix:
Gender:M
Credentials:DC
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 902
Mailing Address - Street 2:1330 E. RICHARDS
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-0902
Mailing Address - Country:US
Mailing Address - Phone:307-358-3147
Mailing Address - Fax:307-358-3213
Practice Address - Street 1:1330 E. RICHARDS
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633
Practice Address - Country:US
Practice Address - Phone:307-358-3147
Practice Address - Fax:307-358-3213
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor