Provider Demographics
NPI:1407277874
Name:SHEHADI, STEPHANIE ROSE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:ROSE
Last Name:SHEHADI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 MONROE AVE
Mailing Address - Street 2:REAR APT 1
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2846
Mailing Address - Country:US
Mailing Address - Phone:570-862-4620
Mailing Address - Fax:
Practice Address - Street 1:106 S CLAUDE A LORD BLVD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3602
Practice Address - Country:US
Practice Address - Phone:570-622-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant