Provider Demographics
NPI:1992773840
Name:STOUT, BRENDA M (PA-C)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:STOUT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:M
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6668 FOURTH SECTION RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2448
Mailing Address - Country:US
Mailing Address - Phone:585-368-6870
Mailing Address - Fax:585-368-6871
Practice Address - Street 1:6555 FOURTH SECTION RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2441
Practice Address - Country:US
Practice Address - Phone:585-315-3644
Practice Address - Fax:585-431-5365
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005069363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03081963Medicaid
NYJ400000836-BA0017Medicare UPIN
NYJ400000837-7008AMedicare UPIN