Basic Information
| Provider Information | |||||||||
| NPI: | 1932445038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FASHINGBAUER | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PA-C, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 E TIMBER DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545012852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153692300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 444 E TIMBER DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545012852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153692300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2012 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 1151 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 5471-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.