Provider Demographics
NPI:1184664484
Name:RHODES, STACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:RHODES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 BEATTIE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-3726
Mailing Address - Country:US
Mailing Address - Phone:970-522-9011
Mailing Address - Fax:
Practice Address - Street 1:1405 S 8TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4563
Practice Address - Country:US
Practice Address - Phone:970-522-3304
Practice Address - Fax:970-522-4615
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13958844Medicaid
CO506048Medicare PIN