1053430876 NPI number — MS. STACIE LYN PATTERSON PA

Table of content: MS. STACIE LYN PATTERSON PA (NPI 1053430876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053430876 NPI number — MS. STACIE LYN PATTERSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATTERSON
Provider First Name:
STACIE
Provider Middle Name:
LYN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MERRITT
Provider Other First Name:
STACIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053430876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13677 W. MC DOWELL ROAD
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
GOODYEAR
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-882-1926
Provider Business Mailing Address Fax Number:
623-882-1709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13677 W. MC DOWELL ROAD
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-882-1926
Provider Business Practice Location Address Fax Number:
623-882-1709
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  5601004376 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: AZ 5154 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0F37698 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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