Provider Demographics
NPI:1245398221
Name:STILLWELL -BARKER, LATONDRA (DMSC, MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:LATONDRA
Middle Name:
Last Name:STILLWELL -BARKER
Suffix:
Gender:F
Credentials:DMSC, MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 WINGATE RD UNIT 48613
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28331-9005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3113
Practice Address - Country:US
Practice Address - Phone:217-383-3270
Practice Address - Fax:217-383-4116
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101921363A00000X
246ZC0007X
GA3135207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant