Provider Demographics
NPI:1699237743
Name:KHENSOURI, STEFAN (PA-C)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:KHENSOURI
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 1:3375 PADDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4328
Mailing Address - Country:US
Mailing Address - Phone:812-278-1825
Mailing Address - Fax:
Practice Address - Street 1:3375 PADDINGTON DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4328
Practice Address - Country:US
Practice Address - Phone:812-278-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant