Provider Demographics
NPI:1376942375
Name:NETHERLAND, STEPHEN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:NETHERLAND
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HHC, 1BSTB, 1ABCT
Mailing Address - Street 2:UNIT # 15046
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96224
Mailing Address - Country:US
Mailing Address - Phone:315-730-8559
Mailing Address - Fax:
Practice Address - Street 1:HHC, 1BSTB, 1ABCT
Practice Address - Street 2:UNIT #15046
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96224
Practice Address - Country:US
Practice Address - Phone:315-730-8559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1117312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant