Healthcare Provider Details

I. General information

NPI: 1871335679
Provider Name (Legal Business Name): DARIN O'SHEA STITES II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 TANK TWO RD
RIDGELY TN
38080-6201
US

IV. Provider business mailing address

1760 TANK TWO RD
RIDGELY TN
38080-6201
US

V. Phone/Fax

Practice location:
  • Phone: 720-512-1046
  • Fax:
Mailing address:
  • Phone: 720-512-1046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6095
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: