Provider Demographics
NPI:1801986476
Name:BAUMGARTNER, STEPHANIE D (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:D
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:CRNA
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 600
Mailing Address - Street 2:167 NORTH MAIN STREET
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2501
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2501
Practice Address - Fax:928-283-2677
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX617253163W00000X
NMR48616163W00000X, 367500000X
SC74541163W00000X
TXAP617253367500000X
SC1356367500000X
IL052041367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ926214Medicaid