Provider Demographics
NPI:1215011796
Name:COOK, STACY MARIE (PA C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:COOK
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:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9925
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:5950 UNIVERSITY AVE STE 151
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-875-9192
Practice Address - Fax:515-875-9193
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA44067002Medicare PIN