Provider Demographics
NPI:1063735959
Name:PETRANCOSTA, STACIA D (PA-C)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:D
Last Name:PETRANCOSTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:D
Other - Last Name:OUTTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9555 PINE CLUSTER CIR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22181-5440
Mailing Address - Country:US
Mailing Address - Phone:910-578-7053
Mailing Address - Fax:
Practice Address - Street 1:500 W ANNANDALE RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046
Practice Address - Country:US
Practice Address - Phone:703-521-6662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical