Provider Demographics
NPI:1245839521
Name:ODOH, STEPHANIE BARONG (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BARONG
Last Name:ODOH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:BARONG
Other - Last Name:CLAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 82969
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2969
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:813-405-3722
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD STE 630
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6399
Practice Address - Country:US
Practice Address - Phone:813-397-5300
Practice Address - Fax:813-876-0590
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9114554363A00000X
TXPA14142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical