Provider Demographics
NPI:1235393851
Name:KIRBY, STACY M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:M
Last Name:KIRBY
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 1:1815 - 1ST AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5417
Mailing Address - Country:US
Mailing Address - Phone:319-363-0474
Mailing Address - Fax:319-363-2170
Practice Address - Street 1:1815 - 1ST AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5417
Practice Address - Country:US
Practice Address - Phone:319-363-0474
Practice Address - Fax:319-363-2170
Is Sole Proprietor?:No
Enumeration Date:2008-07-13
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IA001929207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1962610725Medicaid
IA127410051Medicare PIN