Provider Demographics
NPI:1265442891
Name:STEPHANOFF, CHRISTOPHER C (PA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:C
Last Name:STEPHANOFF
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9350
Mailing Address - Country:US
Mailing Address - Phone:843-572-9211
Mailing Address - Fax:843-572-0457
Practice Address - Street 1:2910 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9350
Practice Address - Country:US
Practice Address - Phone:843-572-9211
Practice Address - Fax:843-572-0457
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA341HEM363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R30096Medicare UPIN