Healthcare Provider Details

I. General information

NPI: 1184612798
Provider Name (Legal Business Name): STEPHEN D. SYLVESTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RU STATION 6899 ADAMS & TYLER STREETS
RADFORD VA
24142
US

IV. Provider business mailing address

316 MOUNTAIN DR
PEARISBURG VA
24134-1120
US

V. Phone/Fax

Practice location:
  • Phone: 540-831-6667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001460
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: