Provider Demographics
NPI:1881662757
Name:PHILIPP, STEPHANIE M (PAC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:M
Last Name:PHILIPP
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-4502
Mailing Address - Country:US
Mailing Address - Phone:830-537-4411
Mailing Address - Fax:
Practice Address - Street 1:8401 DATAPOINT DR
Practice Address - Street 2:SUITE 500
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5900
Practice Address - Country:US
Practice Address - Phone:210-614-0180
Practice Address - Fax:210-614-1722
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 04390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8E0089Medicare UPIN