Provider Demographics
NPI:1235720830
Name:VLADOVICH, STACEY ERIKA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ERIKA
Last Name:VLADOVICH
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 1:637 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5222
Mailing Address - Country:US
Mailing Address - Phone:918-289-6496
Mailing Address - Fax:
Practice Address - Street 1:637 E 27TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5222
Practice Address - Country:US
Practice Address - Phone:918-289-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant