Provider Demographics
NPI:1245263268
Name:STOUT, WILLIAM JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:STOUT
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 1:7007 POWERS BLVD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5437
Mailing Address - Country:US
Mailing Address - Phone:440-743-3000
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:815-968-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
K53321Medicare PIN