Provider Demographics
NPI:1649890039
Name:STODDARD, ANNA GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:GRACE
Last Name:STODDARD
Suffix:
Gender:F
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 1:804 PINCKNEY ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-4746
Mailing Address - Country:US
Mailing Address - Phone:843-441-1359
Mailing Address - Fax:
Practice Address - Street 1:989 RIBAUT RD STE 360
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5427
Practice Address - Country:US
Practice Address - Phone:843-524-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400676Medicaid