Provider Demographics
NPI:1134262710
Name:THERIAULT, STEPHEN EMILE (PA-C)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:EMILE
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1341 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3235
Mailing Address - Country:US
Mailing Address - Phone:321-953-1225
Mailing Address - Fax:321-768-0033
Practice Address - Street 1:1341 MEDICAL PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3235
Practice Address - Country:US
Practice Address - Phone:321-953-1225
Practice Address - Fax:321-768-0033
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH0227363AM0700X
FLPA9104153363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292994500Medicaid
FLAH652ZMedicare UPIN