Provider Demographics
NPI:1790150498
Name:FORD, STEFANI R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEFANI
Middle Name:R
Last Name:FORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:STEFANI
Other - Middle Name:R
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2860
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-2860
Mailing Address - Country:US
Mailing Address - Phone:501-315-4008
Mailing Address - Fax:501-315-3411
Practice Address - Street 1:1000 HIGHWAY 35 N
Practice Address - Street 2:SUITE 8
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2351
Practice Address - Country:US
Practice Address - Phone:501-315-4008
Practice Address - Fax:501-315-3411
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-626363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical