Provider Demographics
NPI:1003887860
Name:GIPE, STACEY BUTLER (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:BUTLER
Last Name:GIPE
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 COPPERFIELD BLVD NE
Practice Address - Street 2:STE 102
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2441
Practice Address - Country:US
Practice Address - Phone:704-786-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101314363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008922039Medicaid
KY95001061Medicaid
VAVVL058B288Medicare PIN
VA970004328Medicare PIN
VA970000152Medicare PIN
VA008922039Medicaid