Provider Demographics
NPI:1104177443
Name:STANIEWSKI, STEPHEN J (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:STANIEWSKI
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 1:2900 S HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-1232
Mailing Address - Country:US
Mailing Address - Phone:410-350-3886
Mailing Address - Fax:
Practice Address - Street 1:2900 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1232
Practice Address - Country:US
Practice Address - Phone:410-350-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004850363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical