Basic Information
| Provider Information | |||||||||
| NPI: | 1730300948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKIDMORE | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 PARK PLACE DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265084521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242887632 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 STADIUM DRIVE PHYSICIAN OFFICE CENTER | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265069196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042933900 | ||||||||
| FaxNumber: | 3042937042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 01048 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.