Healthcare Provider Details

I. General information

NPI: 1528313350
Provider Name (Legal Business Name): STEPHANIE ELAINE FANGMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 W MAIN ST STE 3
MANCHESTER IA
52057-1526
US

IV. Provider business mailing address

709 W MAIN ST STE 3
MANCHESTER IA
52057-1526
US

V. Phone/Fax

Practice location:
  • Phone: 563-927-7698
  • Fax: 269-349-2898
Mailing address:
  • Phone: 563-927-7777
  • Fax: 269-226-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601006398
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: