Basic Information
Provider Information | |||||||||
NPI: | 1952506420 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STAFFORD CREEK CORRECTION CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 191 CONSTANTINE WAY | ||||||||
Address2: |   | ||||||||
City: | ABERDEEN | ||||||||
State: | WA | ||||||||
PostalCode: | 985209504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605372167 | ||||||||
FaxNumber: | 3605372075 | ||||||||
Practice Location | |||||||||
Address1: | 191 CONSTANTINE WAY | ||||||||
Address2: |   | ||||||||
City: | ABERDEEN | ||||||||
State: | WA | ||||||||
PostalCode: | 985209504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605372167 | ||||||||
FaxNumber: | 3605372075 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STERN | ||||||||
AuthorizedOfficialFirstName: | MARC | ||||||||
AuthorizedOfficialMiddleName: | F. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, HEALTH SERVICES DOC | ||||||||
AuthorizedOfficialTelephone: | 3607258700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X |   |   | X |   | Agencies | Public Health or Welfare |   | 311Z00000X |   |   | X |   | Nursing & Custodial Care Facilities | Custodial Care Facility |   | 363A00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363LA2200X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.