Healthcare Provider Details

I. General information

NPI: 1396254009
Provider Name (Legal Business Name): STACY EDGAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-1939
  • Fax: 740-374-1693
Mailing address:
  • Phone: 304-483-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3013
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007485
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10002314A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007774RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: