Provider Demographics
NPI:1376535054
Name:CARTER, STEPHANIE S (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
Last Name:CARTER
Suffix:
Gender:F
Credentials:PA-C
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:703 S FLEISHEL AVE STE 4000
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-606-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-042OtherTRICARE
TX846N82OtherBCBS
TX184586901Medicaid
TX8N8507OtherBCBS OF TEXAS
TXP02007954OtherMEDICARE RAIL ROAD
TX184586902Medicaid
TX184586901Medicaid
TX8N8507OtherBCBS OF TEXAS
TX8D5677Medicare ID - Type Unspecified
TXTXB131580Medicare PIN