Healthcare Provider Details

I. General information

NPI: 1720868045
Provider Name (Legal Business Name): STEPHANIE HSIEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38001 OLD STAGE RD
GUALALA CA
95445-8543
US

IV. Provider business mailing address

PO BOX 1196
GUALALA CA
95445-1196
US

V. Phone/Fax

Practice location:
  • Phone: 707-412-3176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA63007
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: