Healthcare Provider Details

I. General information

NPI: 1659711679
Provider Name (Legal Business Name): STEPHANIE R MABIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 HEALTH CARE LN
MARTINSBURG WV
25401-4009
US

IV. Provider business mailing address

2500 FOUNDATION WAY
MARTINSBURG WV
25401-9000
US

V. Phone/Fax

Practice location:
  • Phone: 304-264-0704
  • Fax: 304-264-0804
Mailing address:
  • Phone: 304-264-9202
  • Fax: 304-264-9042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA056192
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2575
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: