Provider Demographics
NPI:1104866763
Name:WINTER, STACY LYNN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:WINTER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9576 HIGHWAY 70
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9067
Mailing Address - Country:US
Mailing Address - Phone:715-358-1000
Mailing Address - Fax:715-358-1156
Practice Address - Street 1:9576 HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9067
Practice Address - Country:US
Practice Address - Phone:715-358-1000
Practice Address - Fax:715-358-1156
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI917363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42965500Medicaid
WI42965500Medicaid