MEDICARE: STACY WILLIAMS JR. PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110008214	VA
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1528722329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY WILLIAMS JR. PA-C

Provider Business Mailing Address
First Line	:	1001 CENTERBROOKE LN
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-8663
Country	:	US
Telephone Number	:	757-702-8105
Fax Number	:	757-702-2186

Provider Business Practice Location Address
First Line	:	1001 CENTERBROOKE LN
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-8663
Country	:	US
Telephone Number	:	757-702-8105
Fax Number	:	757-702-2186

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2021
Last Update Date	:	03/09/2026

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