Provider Demographics
NPI:1073853545
Name:HOGAN, STACEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HOGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2121 HUGHES DR
Mailing Address - Street 2:#310
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3845
Mailing Address - Country:US
Mailing Address - Phone:419-291-3858
Mailing Address - Fax:419-480-8701
Practice Address - Street 1:2121 HUGHES DR
Practice Address - Street 2:#310
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3845
Practice Address - Country:US
Practice Address - Phone:419-291-3858
Practice Address - Fax:419-480-8701
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096437Medicaid
OH1109583OtherNATONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
OH1109583OtherNATONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS