Provider Demographics
NPI:1518197672
Name:RILEY, STEPHANIE ALEXANDER (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALEXANDER
Last Name:RILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ALEXANDER
Other - Last Name:NUNEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10254 CARRY BACK CIR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-5812
Mailing Address - Country:US
Mailing Address - Phone:312-576-7674
Mailing Address - Fax:
Practice Address - Street 1:5461 LA SIERRA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4107
Practice Address - Country:US
Practice Address - Phone:214-692-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004114363A00000X
LAPA.200289363AS0400X
TXPA11231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1801755Medicaid
LAPC01Medicare PIN
LAP00883084Medicare PIN