Provider Demographics
NPI:1275781387
Name:SANTOSTEFANO, RICHARD SR
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:SANTOSTEFANO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 10TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3580
Mailing Address - Country:US
Mailing Address - Phone:304-529-0753
Mailing Address - Fax:304-529-0591
Practice Address - Street 1:1448 10TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3580
Practice Address - Country:US
Practice Address - Phone:304-529-0753
Practice Address - Fax:304-529-0591
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV723363AM0700X
WV13363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical