Healthcare Provider Details

I. General information

NPI: 1518021120
Provider Name (Legal Business Name): STANLEY CYRIL WORM PHYSICIAN EXTENDER R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WILLMAR AVE SW AFFILIATED COMMUNITY MEDICAL CENTERS
WILLMAR MN
56201
US

IV. Provider business mailing address

101 WILLMAR AVE SW ACMC
WILLMAR MN
56201
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5000
  • Fax: 320-231-5067
Mailing address:
  • Phone: 320-231-5000
  • Fax: 320-231-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8968
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: