1952556193 NPI number — STACY ELLEN SHIMP PA-C

Table of content: STACY ELLEN SHIMP PA-C (NPI 1952556193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952556193 NPI number — STACY ELLEN SHIMP PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIMP
Provider First Name:
STACY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VOEGELI
Provider Other First Name:
STACY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952556193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19732-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-651-4200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 ROCKLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19803-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-651-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  002208 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: MA054808 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MA054808 . This is a "PENNSYLVANIA MEDICAL STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".