Healthcare Provider Details

I. General information

NPI: 1609343821
Provider Name (Legal Business Name): STEPHEN MICHAEL STAUDT JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 JOHN F KENNEDY DR
ATLANTIS FL
33462-6641
US

IV. Provider business mailing address

10132 CAOBA ST
PALM BEACH GARDENS FL
33410-5123
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-6500
  • Fax:
Mailing address:
  • Phone: 561-628-3045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9111157
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: