Provider Demographics
NPI:1134449614
Name:STACKMAN, JAMIE LICHTENSTEIN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LICHTENSTEIN
Last Name:STACKMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:NICOLE
Other - Last Name:LICHTENSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7 GRANITE PLACE, SUITE 14
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-3201
Mailing Address - Country:US
Mailing Address - Phone:240-631-1170
Mailing Address - Fax:
Practice Address - Street 1:7 GRANITE PL STE 14
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-6607
Practice Address - Country:US
Practice Address - Phone:240-631-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1134449614Medicare NSC