Provider Demographics
NPI:1619225828
Name:KEPHART, STACI (PA)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:KEPHART
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 1:850 MAIN STREET
Mailing Address - Street 2:PO BOX 375
Mailing Address - City:COALPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16627
Mailing Address - Country:US
Mailing Address - Phone:814-672-5141
Mailing Address - Fax:814-672-5461
Practice Address - Street 1:850 MAIN STREET
Practice Address - Street 2:
Practice Address - City:COALPORT
Practice Address - State:PA
Practice Address - Zip Code:16627
Practice Address - Country:US
Practice Address - Phone:814-672-5141
Practice Address - Fax:814-672-5461
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant