Provider Demographics
NPI:1386668655
Name:WALKER, STACEY ANN (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:WALKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:14 MAIDEN LN
Mailing Address - Street 2:PO BOX 423
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1208
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:112 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1816
Practice Address - Country:US
Practice Address - Phone:315-536-2752
Practice Address - Fax:315-536-4005
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-02-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY239852207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY239852OtherLICENSE
NY02799228Medicaid
NYJ400330022Medicare PIN