Healthcare Provider Details

I. General information

NPI: 1760594154
Provider Name (Legal Business Name): STEPHEN ANDREW FALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 COFFEE RD STE 100
MODESTO CA
95355-3192
US

IV. Provider business mailing address

3838 NORTH AVE
MODESTO CA
95358-8936
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-4438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: