Provider Demographics
NPI:1275835852
Name:RIVERS, STEPHANIE ANN (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:RIVERS
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 1:1505 STONEBRIDGE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8282
Mailing Address - Country:US
Mailing Address - Phone:770-423-0595
Mailing Address - Fax:
Practice Address - Street 1:61 WHITCHER STREET NE
Practice Address - Street 2:SUITE 2100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1179
Practice Address - Country:US
Practice Address - Phone:770-423-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6001363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical