Provider Demographics
NPI:1578865176
Name:CONDON, STEPHANIE JOAN (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JOAN
Last Name:CONDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:JOAN
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:7116 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2904
Practice Address - Country:US
Practice Address - Phone:443-577-0277
Practice Address - Fax:443-577-0288
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD556964YVZMedicare PIN
MD556964ZDDBMedicare PIN
MD556222YWV2Medicare PIN