Provider Demographics
NPI:1750531448
Name:WILCHINSKI, STEPHANIE A (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:A
Last Name:WILCHINSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MUNDY ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6830
Mailing Address - Country:US
Mailing Address - Phone:570-824-0930
Mailing Address - Fax:
Practice Address - Street 1:150 MUNDY STREET
Practice Address - Street 2:MAC IV BUILDING
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-824-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
PAMA053663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50150951OtherCAPITAL BLUE CROSS
PA134572J67OtherMEDICARE