Provider Demographics
NPI:1164781381
Name:NEUDORF, STACY ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ELAINE
Last Name:NEUDORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ELAINE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:4015 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1119
Practice Address - Country:US
Practice Address - Phone:806-725-0030
Practice Address - Fax:806-725-0015
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96877553Medicaid
NM96877553Medicaid