Provider Demographics
NPI:1700994118
Name:SHORTRIDGE, STEPHEN MATTHEW (PAC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MATTHEW
Last Name:SHORTRIDGE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3066 E MERIDIAN PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7372
Mailing Address - Country:US
Mailing Address - Phone:907-373-9460
Mailing Address - Fax:907-373-9461
Practice Address - Street 1:3066 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7372
Practice Address - Country:US
Practice Address - Phone:907-373-9460
Practice Address - Fax:907-373-9461
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020264Medicaid
AK1020264Medicaid