Provider Demographics
NPI:1164462156
Name:STUCKY, SHEA R (PA)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:R
Last Name:STUCKY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 N HILLSIDE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4928
Mailing Address - Country:US
Mailing Address - Phone:316-685-0559
Mailing Address - Fax:316-685-0455
Practice Address - Street 1:551 N HILLSIDE ST STE 510
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4928
Practice Address - Country:US
Practice Address - Phone:316-685-0559
Practice Address - Fax:316-685-0455
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08798Medicare UPIN
042557Medicare ID - Type Unspecified