Healthcare Provider Details

I. General information

NPI: 1588815559
Provider Name (Legal Business Name): STACIE GONZALEZ VELEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACIE GONZALEZ PA-C

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 07/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 GB ALFORD HWY
HOLLY SPRINGS NC
27540-7661
US

IV. Provider business mailing address

7212 GB ALFORD HWY
HOLLY SPRINGS NC
27540-7661
US

V. Phone/Fax

Practice location:
  • Phone: 919-552-1520
  • Fax: 919-552-8792
Mailing address:
  • Phone: 919-552-1520
  • Fax: 919-552-8792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-01503
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: