1194677955 NPI number — STACY PETERSEN MEDICAL GROUP, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194677955 NPI number — STACY PETERSEN MEDICAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STACY PETERSEN MEDICAL GROUP, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194677955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26791 ALISO CREEK RD # 1018
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALISO VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92656-2887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
949-288-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4445 MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-991-4172
Provider Business Practice Location Address Fax Number:
949-288-0429
Provider Enumeration Date:
02/12/2026

Additional Information

Authorized Official

Authorized Official Last Name:
DIFLEY
Authorized Official First Name:
STACY
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
949-991-4172

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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