Provider Information for 1053673582
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STEPHANIE MARIE WOGOMON
Other Names:Former Name:STEPHANIE MARIE ACOSTASex: Female
NPI: 1053673582
Last Updated: 2024-04-22
Certification Date: 2024-04-22
Certification Date: 2024-04-22
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1053673582 | ||||||||
| Enumeration Date | 2012-06-11 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 10439 S 51ST ST STE 100 PHOENIX, AZ 85044-5224 United States Phone: 909-395-6602 | Fax: | ||||||||
| Primary Practice Address | 10439 S 51ST ST STE 100 PHOENIX, AZ 85044-5224 United States Phone: 480-635-9944 | Fax: | ||||||||
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