Provider Demographics
NPI:1922811983
Name:WILSON, STEPHANIE DIANE (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4702
Mailing Address - Country:US
Mailing Address - Phone:970-903-2778
Mailing Address - Fax:
Practice Address - Street 1:5600 S QUEBEC ST STE 312A
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2208
Practice Address - Country:US
Practice Address - Phone:303-436-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0008872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant