Provider Demographics
NPI:1073560272
Name:BENECK, STACEY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:BENECK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 THUNDER RD
Mailing Address - Street 2:STE 140
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-334-0320
Mailing Address - Fax:855-330-7320
Practice Address - Street 1:905 THUNDER RD
Practice Address - Street 2:STE 140
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-334-0320
Practice Address - Fax:855-330-7320
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-664363A00000X
NC0010-06505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES97539Medicare UPIN
MEAP117501Medicare PIN
MEAP1175Medicare PIN