Provider Demographics
NPI:1164836201
Name:HLADISH, STACEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HLADISH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:MROCZENSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:1111 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5548
Practice Address - Country:US
Practice Address - Phone:920-682-6376
Practice Address - Fax:920-652-0115
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3310-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant