Provider Demographics
NPI:1144235003
Name:RIETZE, STACEY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ALAN
Last Name:RIETZE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WEST 5TH AVE
Mailing Address - Street 2:SUITE 230E
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2483
Mailing Address - Country:US
Mailing Address - Phone:509-838-8828
Mailing Address - Fax:509-835-4058
Practice Address - Street 1:104 WEST 5TH AVE
Practice Address - Street 2:SUITE 230E
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2483
Practice Address - Country:US
Practice Address - Phone:509-838-8828
Practice Address - Fax:509-835-4058
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042358207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8372658Medicaid
WA8372658Medicaid
AB37784Medicare ID - Type Unspecified