Basic Information
| Provider Information | |||||||||
| NPI: | 1306379607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERTWIG | ||||||||
| FirstName: | STEPHENE | ||||||||
| MiddleName: | AIZCORBE | ||||||||
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| Credential: | RN, MSN, ACNPC-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 MEADOW VISTA LOOP UNIT D | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599012936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036264640 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 350 HERITAGE WAY STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062578992 | ||||||||
| FaxNumber: | 4062578996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2017 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 0024174096 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LC0200X | NUR-APRN-LIC-184834 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LC0200X | 0024174096 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.