Provider Demographics
NPI:1700096583
Name:STOCUM, RENNY JOE (PA)
Entity type:Individual
Prefix:
First Name:RENNY
Middle Name:JOE
Last Name:STOCUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 COLISEUM DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5975
Mailing Address - Country:US
Mailing Address - Phone:757-736-1520
Mailing Address - Fax:
Practice Address - Street 1:4000 COLISEUM DR STE 200A
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5975
Practice Address - Country:US
Practice Address - Phone:757-736-1520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007239363A00000X
VA0110007831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02499705Medicaid
NYP03204Medicare UPIN
NY02499705Medicaid