Healthcare Provider Details

I. General information

NPI: 1902838162
Provider Name (Legal Business Name): STACY WAYNE DENNIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 SGT PRENTISS DR SUITE 103
NATCHEZ MS
39120-4792
US

IV. Provider business mailing address

46 SGT PRENTISS DR SUITE 103
NATCHEZ MS
39120-4792
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-9654
  • Fax: 601-442-9790
Mailing address:
  • Phone: 601-442-9654
  • Fax: 601-442-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA040
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: