Provider Demographics
NPI:1396703740
Name:STAUFFER, JACK ALLAN (FNP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ALLAN
Last Name:STAUFFER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SIGMA DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7715
Mailing Address - Country:US
Mailing Address - Phone:843-554-8312
Mailing Address - Fax:843-554-5141
Practice Address - Street 1:435 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6407
Practice Address - Country:US
Practice Address - Phone:843-873-1592
Practice Address - Fax:843-820-3373
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00851396OtherRR MEDICARE PTAN
SCNP0021Medicaid
SCSC46485277Medicare PIN
SCSC46485282Medicare PIN
SCSC46487498Medicare PIN
SCSC46486868Medicare PIN
SCSC46487819Medicare PIN
SCQ31903Medicare UPIN
SCP00851396OtherRR MEDICARE PTAN
SCQ319037522Medicare PIN
SCSC46488798Medicare PIN
SCSC46487006Medicare PIN
SCSC46486834Medicare PIN
SCSC46485281Medicare PIN
SCNP0021Medicaid
SCSC46486882Medicare PIN
SCSC46487499Medicare PIN