MEDICARE: STEPHANIE BLACK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	50.005194RX	OH

General Provider Information

NPI Number	:	1083124051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE BLACK PA-C

Provider Business Mailing Address
First Line	:	1455 HARRISON AVE NW STE 105
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-2609
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1455 HARRISON AVE NW STE 105
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-2609
Country	:	US
Telephone Number	:	330-453-9993
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2017
Last Update Date	:	10/04/2017

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Directions to “ STEPHANIE BLACK PA-C” Practice Location

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