Provider Demographics
NPI:1811713464
Name:STAN, WANDA (PA-C)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:STAN
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 1:3609 TRILLIUM DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7232
Mailing Address - Country:US
Mailing Address - Phone:770-685-9901
Mailing Address - Fax:
Practice Address - Street 1:695 KINKAID RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21402-1006
Practice Address - Country:US
Practice Address - Phone:443-822-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant