Provider Demographics
NPI:1003400409
Name:KEGEL, STACY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:KEGEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 W OGDEN AVE # CLINICG
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3765
Mailing Address - Country:US
Mailing Address - Phone:312-864-6000
Mailing Address - Fax:
Practice Address - Street 1:1969 W OGDEN AVE # CLINICG
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3765
Practice Address - Country:US
Practice Address - Phone:312-864-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant