Provider Demographics
NPI:1295743847
Name:GITTLER, STACY L (PA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:GITTLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 BREMO RD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1930
Mailing Address - Country:US
Mailing Address - Phone:804-285-4133
Mailing Address - Fax:804-622-2224
Practice Address - Street 1:5855 BREMO RD
Practice Address - Street 2:SUITE 406
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1930
Practice Address - Country:US
Practice Address - Phone:804-285-4133
Practice Address - Fax:804-622-2224
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052610363AS0400X
VA0110002656363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VAC06695OtherGROUP PTAN