Provider Demographics
NPI:1548594294
Name:TOLBERT, STEPHANI MYRA (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANI
Middle Name:MYRA
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:PA
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 7206
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-7206
Mailing Address - Country:US
Mailing Address - Phone:800-355-0808
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:443-777-7068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant