Healthcare Provider Details

I. General information

NPI: 1073031761
Provider Name (Legal Business Name): STEPHANIE KLOTH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 GEORGIANA ST
PORT ANGELES WA
98362-3911
US

IV. Provider business mailing address

PO BOX 850
PORT ANGELES WA
98362-0146
US

V. Phone/Fax

Practice location:
  • Phone: 360-565-0999
  • Fax: 360-565-9251
Mailing address:
  • Phone: 360-565-0999
  • Fax: 360-565-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60922980
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60922980
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: