Provider Demographics
NPI:1164833240
Name:SCHMOLL, STEPHEN (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SCHMOLL
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5627
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:205 E NASA BLVD FL 1
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1950
Practice Address - Country:US
Practice Address - Phone:321-361-5627
Practice Address - Fax:321-728-4135
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107951363A00000X
FLPA 9107951363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015647700Medicaid
FLHU680YOtherMEDICARE