Provider Demographics
NPI:1063793222
Name:BRANDENBURG, STACIA E (PA-C)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:E
Last Name:BRANDENBURG
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 1:9901 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3357
Mailing Address - Country:US
Mailing Address - Phone:240-826-7550
Mailing Address - Fax:
Practice Address - Street 1:25500 POINT LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2015
Practice Address - Country:US
Practice Address - Phone:240-826-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21790363A00000X
MDC0005910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant