Provider Demographics
NPI:1316581432
Name:CAMPOS, STEFANIE LOBO
Entity Type:Individual
Prefix:MS
First Name:STEFANIE
Middle Name:LOBO
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-3054
Mailing Address - Fax:
Practice Address - Street 1:79-01 BROADWAY
Practice Address - Street 2:
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11373-9101
Practice Address - Country:US
Practice Address - Phone:718-334-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty