Healthcare Provider Details

I. General information

NPI: 1770032948
Provider Name (Legal Business Name): AUSTIN MICHAEL STALLINGS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 10/11/2023
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 RUSHING DR
HERRIN IL
62948-3730
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-3300
  • Fax: 618-993-0262
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006012
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: