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General NPI Number Information
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NPI Number | 1376569889
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Entity Type | Individual
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Provider Name | TRICIA J STORTEBOOM PA
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Gender | Female
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 04/21/2023
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Provider Practice Location Address
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Address Line | 790 CHURCH ST NE
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City | MARIETTA
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State | GA
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Zip | 30060-7282
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Country | US
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Telephone | 770-405-2976
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Fax | 770-988-0730
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Provider Business Mailing Address
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Address Line | PO BOX 3157
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City | INDIANAPOLIS
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State | IN
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Zip | 46206-3157
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Country | US
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Telephone | 770-405-2976
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Fax | 770-988-0730
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9104129
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9104129
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 9752
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License Number State | GA
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