Provider Demographics
NPI:1407107501
Name:STOUT, STEPHANIE BUCKLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BUCKLEY
Last Name:STOUT
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 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:10305 HAMPTONS PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7217
Practice Address - Country:US
Practice Address - Phone:704-295-3600
Practice Address - Fax:704-892-3181
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1407107501Medicaid
NC1733POtherBCBSNC
4812523OtherAETNA
SC1506PAMedicaid
NCNC9009FMedicare PIN
NC1407107501Medicaid
NCNC9009EMedicare PIN
SC1506PAMedicaid
NCNC9009HMedicare PIN
NCNC9009DMedicare PIN