Provider Demographics
NPI:1225266497
Name:STOVALL, KATHRYN RISSE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:RISSE
Last Name:STOVALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 BEN FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2147
Mailing Address - Country:US
Mailing Address - Phone:919-477-3005
Mailing Address - Fax:919-477-5526
Practice Address - Street 1:309 NEW ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3654
Practice Address - Country:US
Practice Address - Phone:336-379-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-01973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant