Healthcare Provider Details

I. General information

NPI: 1700096583
Provider Name (Legal Business Name): RENNY JOE STOCUM P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5589 GREENWICH RD STE 100
VIRGINIA BEACH VA
23462-6565
US

IV. Provider business mailing address

4000 COLISEUM DR STE 200A
HAMPTON VA
23666-5975
US

V. Phone/Fax

Practice location:
  • Phone: 888-628-8272
  • Fax:
Mailing address:
  • Phone: 757-736-1520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007831
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007239
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: