Provider Demographics
NPI:1548519986
Name:GOEDE, STEPHANIE H (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:H
Last Name:GOEDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:H
Other - Last Name:STOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:420 N IL ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3709
Mailing Address - Country:US
Mailing Address - Phone:815-356-5200
Mailing Address - Fax:815-356-5262
Practice Address - Street 1:420 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-356-5200
Practice Address - Fax:815-356-5262
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004468363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1108763OtherNCCPA
IL085004468OtherSTATE LICENSE