Provider Demographics
NPI:1366852063
Name:STOVER, CYNTHIA D (PA-C)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:STOVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:D
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6807
Mailing Address - Country:US
Mailing Address - Phone:803-335-1219
Mailing Address - Fax:803-335-1689
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2103363AM0700X
WI4313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100077887Medicaid
SC1935PAMedicaid
SC1935PAMedicaid
SCMS3366021OtherDEA