Provider Demographics
NPI:1902838162
Name:DENNIS, STACY WAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:WAYNE
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:46 SGT PRENTISS DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4792
Mailing Address - Country:US
Mailing Address - Phone:601-442-9654
Mailing Address - Fax:601-442-9790
Practice Address - Street 1:46 SGT PRENTISS DR
Practice Address - Street 2:SUITE 103
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4792
Practice Address - Country:US
Practice Address - Phone:601-442-9654
Practice Address - Fax:601-442-9790
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS73209Medicare UPIN
MS970000046Medicare ID - Type UnspecifiedMEDICARE NUMBER