Provider Demographics
NPI:1205027620
Name:ROYCE, STACEY BISPHAM (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:BISPHAM
Last Name:ROYCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:E
Other - Last Name:BISPHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6001 21ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7847
Mailing Address - Country:US
Mailing Address - Phone:941-761-4448
Mailing Address - Fax:941-761-0235
Practice Address - Street 1:6001 21ST AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7847
Practice Address - Country:US
Practice Address - Phone:941-761-4448
Practice Address - Fax:941-761-0235
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104208OtherSTATE LICENSE NUMBER