Provider Demographics
NPI:1326039769
Name:STEFANOVICH, STEFAN JOHN JR (PA)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:JOHN
Last Name:STEFANOVICH
Suffix:JR
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-677-3961
Mailing Address - Fax:518-677-3180
Practice Address - Street 1:35 GILBERT ST
Practice Address - Street 2:CAMBRIDGE FAMILY HEALTH CENTER
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-2618
Practice Address - Country:US
Practice Address - Phone:518-677-3961
Practice Address - Fax:518-677-3180
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347377Medicaid
NYP00031872OtherRR MEDICARE
S63110Medicare UPIN
NY02347377Medicaid