Provider Demographics
NPI:1912077645
Name:BECKETT, STACIE LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LEIGH
Last Name:BECKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1878
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-1878
Mailing Address - Country:US
Mailing Address - Phone:304-236-5029
Mailing Address - Fax:
Practice Address - Street 1:859 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3215
Practice Address - Country:US
Practice Address - Phone:304-235-2500
Practice Address - Fax:304-235-4549
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV00960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003679Medicaid
WVP86538Medicare UPIN
WVFLPA20921Medicare ID - Type Unspecified