Provider Demographics
NPI:1619461126
Name:STACEY, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STACEY
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 1:2415 MUSGROVE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-5228
Mailing Address - Country:US
Mailing Address - Phone:301-989-2300
Mailing Address - Fax:301-236-5357
Practice Address - Street 1:2415 MUSGROVE RD STE 203
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-5228
Practice Address - Country:US
Practice Address - Phone:301-989-2300
Practice Address - Fax:301-236-5357
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant