Provider Demographics
NPI:1093317646
Name:STAVERSKY, MICHAEL R (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:STAVERSKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:3495 IRON HORSE RD
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4319
Practice Address - Country:US
Practice Address - Phone:843-793-5970
Practice Address - Fax:843-419-5391
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4578PAMedicaid