Basic Information
| Provider Information | |||||||||
| NPI: | 1588815559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELEZ | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | GONZALEZ | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GONZALEZ | ||||||||
| OtherFirstName: | STACIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7212 GB ALFORD HWY | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275407661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195521520 | ||||||||
| FaxNumber: | 9195528792 | ||||||||
| Practice Location | |||||||||
| Address1: | 7212 GB ALFORD HWY | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275407661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195521520 | ||||||||
| FaxNumber: | 9195528792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2008 | ||||||||
| LastUpdateDate: | 07/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-01503 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.