Provider Demographics
NPI:1043625296
Name:SUTTON, STACI
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:SUTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7630 N BEACH ST STE 140
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3016
Mailing Address - Country:US
Mailing Address - Phone:817-281-2977
Mailing Address - Fax:817-788-2530
Practice Address - Street 1:7630 N BEACH ST STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3016
Practice Address - Country:US
Practice Address - Phone:817-281-2977
Practice Address - Fax:817-788-2530
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360010YKPWMedicare PIN