Healthcare Provider Details

I. General information

NPI: 1609933985
Provider Name (Legal Business Name): STACY CARR PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 EUREKA ST SUITE B
WEATHERFORD TX
76086-5880
US

IV. Provider business mailing address

907 EUREKA ST SUITE B
WEATHERFORD TX
76086-5880
US

V. Phone/Fax

Practice location:
  • Phone: 817-599-4901
  • Fax: 325-646-9454
Mailing address:
  • Phone: 817-599-4901
  • Fax: 325-646-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA04567
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: