Provider Demographics
NPI:1770078016
Name:STADER, JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:STADER
Suffix:
Gender:M
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 1:9177 OLD POTOSI RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-9437
Mailing Address - Country:US
Mailing Address - Phone:608-723-4300
Mailing Address - Fax:
Practice Address - Street 1:9177 OLD POTOSI RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-9437
Practice Address - Country:US
Practice Address - Phone:608-723-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4441-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4441-23OtherSTATE OF WISCONSIN