Healthcare Provider Details

I. General information

NPI: 1114535077
Provider Name (Legal Business Name): JONATHAN STEPHENS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 CYPRESS CIR STE 300
CONWAY SC
29526-8995
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATT PNS CREDENTIALING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-8041
  • Fax:
Mailing address:
  • Phone: 843-234-6996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number025354
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6378
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: