Provider Demographics
NPI:1992839286
Name:MCCARTY WILSON, STACY RENE (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:RENE
Last Name:MCCARTY WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13129
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:939 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3901
Practice Address - Country:US
Practice Address - Phone:503-561-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007022061207V00000X
ORMD152435207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology