Healthcare Provider Details

I. General information

NPI: 1194706028
Provider Name (Legal Business Name): RICK STOLTENBURG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E 7TH ST
PLATTE SD
57369-2123
US

IV. Provider business mailing address

601 E 7TH ST
PLATTE SD
57369-2123
US

V. Phone/Fax

Practice location:
  • Phone: 605-337-3364
  • Fax: 605-337-2670
Mailing address:
  • Phone: 605-337-3364
  • Fax: 605-337-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0377
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: