Basic Information
| Provider Information | |||||||||
| NPI: | 1194719013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCUM | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LEIGH MURPHY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 PAGE RD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 REGIONAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102353448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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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 | 103357 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01645409 | 01 | NC | RR MEDICARE | OTHER | 1194719013 | 05 | NC | MEDICAID |