Provider Demographics
NPI:1528344926
Name:SYDNEY, STEPHANIE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:SYDNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:S
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:240-964-8724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MDC04552363A00000X
FLPA9116262363A00000X
COPA.0008276363A00000X
VA0110003700363AS0400X
IN10002414A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011151Medicaid
KY7100369110Medicaid