Provider Demographics
NPI:1790275287
Name:STAWNICZY, ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:STAWNICZY
Suffix:
Gender:M
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:PO BOX 2181
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91769-2181
Mailing Address - Country:US
Mailing Address - Phone:909-754-8209
Mailing Address - Fax:
Practice Address - Street 1:309 E 2ND ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1854
Practice Address - Country:US
Practice Address - Phone:909-469-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP-23257146L00000X
CAPA55876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic