Provider Demographics
NPI:1033402151
Name:DAVIS, STEPHANIE KIRBY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:KIRBY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:BOIST
Other - Last Name:KIRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4734
Mailing Address - Country:US
Mailing Address - Phone:864-716-0063
Mailing Address - Fax:864-716-0073
Practice Address - Street 1:1501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-716-0063
Practice Address - Fax:864-716-0073
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003111148AMedicaid
GA202I974482Medicare PIN