Provider Demographics
NPI:1245396977
Name:SKALTSOUNIS, STACY NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:SKALTSOUNIS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:586-731-8400
Mailing Address - Fax:586-731-8406
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:SUITE 340
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-731-8400
Practice Address - Fax:586-731-8406
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2015-07-06
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Provider Licenses
StateLicense IDTaxonomies
MI5601004001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP24580025Medicare PIN