Provider Demographics
NPI:1164490710
Name:PIERCE, STACIE L (PA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:PIERCE
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 1:3000 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1818
Mailing Address - Country:US
Mailing Address - Phone:405-632-6688
Mailing Address - Fax:
Practice Address - Street 1:1025 STRAKA TER
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2544
Practice Address - Country:US
Practice Address - Phone:405-632-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2809101Y00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP59426Medicare UPIN
MO97270Medicare ID - Type Unspecified