Basic Information
| Provider Information | |||||||||
| NPI: | 1073084984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALDRON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, STE. 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 411B PARK HILL DR | ||||||||
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| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224013376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110006581 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.