Provider Demographics
NPI:1134243280
Name:WEGNER, STACY LADAWN (PA-C)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:LADAWN
Last Name:WEGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:LADAWN
Other - Last Name:POND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3454 SHEA RD
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-9738
Mailing Address - Country:US
Mailing Address - Phone:312-550-2558
Mailing Address - Fax:
Practice Address - Street 1:1458 W. POPLAR AVE
Practice Address - Street 2:STE 200
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017
Practice Address - Country:US
Practice Address - Phone:901-850-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001529363A00000X
TN085001529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant