Provider Demographics
NPI:1235245861
Name:ECCLESTON, STEPHANIE S (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
Last Name:ECCLESTON
Suffix:
Gender:F
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 1:4 BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2676
Mailing Address - Country:US
Mailing Address - Phone:781-953-5611
Mailing Address - Fax:
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2165363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP268902Medicare PIN