Basic Information
| Provider Information | |||||||||
| NPI: | 1649581331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORTNER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JUNE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3396 FLINT HILL PL | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221927101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 23RD ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200372342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027154000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9016093 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 006061 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-02382 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0010-02382 | 01 | NC | NC LICENSE | OTHER |