Provider Demographics
NPI:1053412569
Name:STACKHOUSE, NORMAN RUSSELL (PA)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:RUSSELL
Last Name:STACKHOUSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9131 PISCATAWAY RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2508
Mailing Address - Country:US
Mailing Address - Phone:301-868-0110
Mailing Address - Fax:301-856-0604
Practice Address - Street 1:9131 PISCATAWAY RD
Practice Address - Street 2:SUITE 600
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2508
Practice Address - Country:US
Practice Address - Phone:301-868-0110
Practice Address - Fax:301-856-0604
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000861363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP38655Medicare UPIN
MD00A631N84Medicare ID - Type UnspecifiedMC IND CLINTON
MD907EMedicare ID - Type UnspecifiedMC IND WLD