Provider Demographics
NPI:1306883574
Name:STANLEY, GERALD N (DO)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:N
Last Name:STANLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7203 W DESCHUTES AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7777
Mailing Address - Country:US
Mailing Address - Phone:509-737-1880
Mailing Address - Fax:509-737-1879
Practice Address - Street 1:7201 W GRANDRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6709
Practice Address - Country:US
Practice Address - Phone:509-783-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1137405Medicaid
WA1137405Medicaid
E32793Medicare UPIN