Provider Demographics
NPI:1235688300
Name:WILSON, STEPHANIE CAROLINE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CAROLINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:CAROLINE
Other - Last Name:RAUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1551 PROFESSIONAL LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6972
Mailing Address - Country:US
Mailing Address - Phone:720-279-9098
Mailing Address - Fax:
Practice Address - Street 1:1551 PROFESSIONAL LN
Practice Address - Street 2:SUITE 220
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6972
Practice Address - Country:US
Practice Address - Phone:720-279-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36125083Medicaid
CO55144YWN5Medicare PIN