Provider Demographics
NPI:1871012112
Name:NEWBERRY, STEPHEN MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:NEWBERRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7199
Mailing Address - Country:US
Mailing Address - Phone:816-835-3004
Mailing Address - Fax:
Practice Address - Street 1:1 S KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7199
Practice Address - Country:US
Practice Address - Phone:816-835-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-012452255A2300X
MO2024006431363A00000X
MO20170326992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer