Provider Demographics
NPI:1730300948
Name:SKIDMORE, STACY LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LEIGH
Last Name:SKIDMORE
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 1:114 PARK PLACE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4521
Mailing Address - Country:US
Mailing Address - Phone:724-288-7632
Mailing Address - Fax:
Practice Address - Street 1:1 STADIUM DRIVE PHYSICIAN OFFICE CENTER
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-9196
Practice Address - Country:US
Practice Address - Phone:304-293-3900
Practice Address - Fax:304-293-7042
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSKPA22661Medicare ID - Type Unspecified
WVP19513Medicare UPIN