Provider Demographics
NPI:1801276712
Name:WIGHT, STEPHANIE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:WIGHT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3702
Mailing Address - Country:US
Mailing Address - Phone:907-374-1686
Mailing Address - Fax:
Practice Address - Street 1:3065 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3702
Practice Address - Country:US
Practice Address - Phone:907-374-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MA20561225100000X
AK121582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002573Medicaid