MEDICARE: STEPHANIE KOURTJIAN PA-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	PA.0008716	CO
2	363AS0400X	Surgical Physician Assistant	5374	WI

General Provider Information

NPI Number	:	1891315495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE KOURTJIAN PA-C

Provider Business Mailing Address
First Line	:	1240 UNIVERSITY BAY DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-2253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 UNIVERSITY BAY DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-2253
Country	:	US
Telephone Number	:	616-970-8072
Fax Number	:

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

Provider Enumeration Date	:	04/23/2020
Last Update Date	:	12/26/2024

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