Healthcare Provider Details

I. General information

NPI: 1295743847
Provider Name (Legal Business Name): STACY L GITTLER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 BREMO RD SUITE 406
RICHMOND VA
23226-1930
US

IV. Provider business mailing address

5855 BREMO RD SUITE 406
RICHMOND VA
23226-1930
US

V. Phone/Fax

Practice location:
  • Phone: 804-285-4133
  • Fax: 804-622-2224
Mailing address:
  • Phone: 804-285-4133
  • Fax: 804-622-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA052610
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110002656
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: