Basic Information
| Provider Information | |||||||||
| NPI: | 1306811732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHO | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 PHILLIPS FIELD RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997093933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593507 | ||||||||
| FaxNumber: | 9074593532 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COWLES ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074585178 | ||||||||
| FaxNumber: | 9074585180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 02/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 464 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MDA0008 | 05 | AK | MEDICAID | MG0408509 | 01 | DEA NUMBER | OTHER |