Provider Demographics
NPI:1104222124
Name:SHOOP, STACEY MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARIE
Last Name:SHOOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2621 S BRISTOL ST
Mailing Address - Street 2:STE 108
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5718
Mailing Address - Country:US
Mailing Address - Phone:714-754-1684
Mailing Address - Fax:714-966-0417
Practice Address - Street 1:2621 S BRISTOL ST
Practice Address - Street 2:STE 108
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5718
Practice Address - Country:US
Practice Address - Phone:714-754-1684
Practice Address - Fax:714-966-0417
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA52143363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical