Provider Demographics
NPI:1588951057
Name:DECARLO, STEPHEN DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DANIEL
Last Name:DECARLO
Suffix:
Gender:M
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 1:4563 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-5326
Mailing Address - Country:US
Mailing Address - Phone:407-461-2560
Mailing Address - Fax:
Practice Address - Street 1:1011 CROSS CUT WAY
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-3078
Practice Address - Country:US
Practice Address - Phone:407-461-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical