Healthcare Provider Details

I. General information

NPI: 1699781120
Provider Name (Legal Business Name): STACY MARIE BRANDT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 MARKET ST
WHEELING WV
26003-2912
US

IV. Provider business mailing address

1038 MARKET ST
WHEELING WV
26003-2912
US

V. Phone/Fax

Practice location:
  • Phone: 304-232-7151
  • Fax: 304-232-6128
Mailing address:
  • Phone: 304-232-7151
  • Fax: 304-232-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01010
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: