MEDICARE: STELLA G WASHINGTON P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	001508	IA
2	363A00000X	Physician Assistant	760	NE

General Provider Information

NPI Number	:	1043321573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STELLA G WASHINGTON P.A.-C

Provider Business Mailing Address
First Line	:	4920 SOUTH 30TH STREET
Second Line	:	SUITE 103
City	:	OMAHA
State	:	NE
Zip	:	68107-1656
Country	:	US
Telephone Number	:	402-734-4110
Fax Number	:	402-991-5642

Provider Business Practice Location Address
First Line	:	4920 SOUTH 30TH STREET
Second Line	:	SUITE 103
City	:	OMAHA
State	:	NE
Zip	:	68107-1656
Country	:	US
Telephone Number	:	402-734-4110
Fax Number	:	402-991-5642

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	11/09/2016

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