Provider Demographics
NPI:1063183150
Name:HALL, STACY (PA-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HALL
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 1:115 SWANSON RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-8669
Mailing Address - Country:US
Mailing Address - Phone:606-269-7899
Mailing Address - Fax:
Practice Address - Street 1:6976 CUMBERLAND GAP PKWY
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8230
Practice Address - Country:US
Practice Address - Phone:423-869-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant