Provider Demographics
NPI:1174718647
Name:HYSON-GUEVARA, STEPHANIE ANN (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:HYSON-GUEVARA
Suffix:
Gender:F
Credentials:PA
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 2016
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-1684
Mailing Address - Country:US
Mailing Address - Phone:770-382-0185
Mailing Address - Fax:770-382-0247
Practice Address - Street 1:40 FOX CHASE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2491
Practice Address - Country:US
Practice Address - Phone:770-382-0185
Practice Address - Fax:770-382-0247
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA806177906BMedicaid
GA806177906AMedicaid
R88633Medicare UPIN
GA806177906AMedicaid