Provider Demographics
NPI:1932229721
Name:OSTRUS, STEPHANIE A (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:OSTRUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:BOERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18700 N 64TH DR STE 301
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7114
Mailing Address - Country:US
Mailing Address - Phone:623-561-5437
Mailing Address - Fax:623-561-2316
Practice Address - Street 1:18700 N 64TH DR STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7114
Practice Address - Country:US
Practice Address - Phone:623-561-5437
Practice Address - Fax:623-561-2316
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ008625Medicaid