Provider Demographics
NPI:1699025742
Name:LANDA, STEPHANIE GISELLE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GISELLE
Last Name:LANDA
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:PO BOX 3725
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3725
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:888-745-3917
Practice Address - Street 1:11750 BIRD RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3530
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:888-745-3917
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant