Provider Demographics
NPI:1285395392
Name:GENSURE, STEFANIE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:NICOLE
Last Name:GENSURE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E MARKET ST # A
Mailing Address - Street 2:
Mailing Address - City:ORWIGSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17961-1906
Mailing Address - Country:US
Mailing Address - Phone:570-778-1816
Mailing Address - Fax:
Practice Address - Street 1:82 TUNNEL RD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3869
Practice Address - Country:US
Practice Address - Phone:570-621-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA20035651801Medicaid