Provider Demographics
NPI:1376543991
Name:CONWAY, STACY J (OD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:CONWAY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-808-5441
Mailing Address - Fax:570-808-5371
Practice Address - Street 1:675 BALTIMORE DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7900
Practice Address - Country:US
Practice Address - Phone:570-808-5441
Practice Address - Fax:570-808-5371
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019617250002Medicaid
PAP00094885OtherPALMETTO GBA-RRMC
PA0019617250001Medicaid
PA0019617250002Medicaid
PA0019617250001Medicaid