Provider Demographics
NPI:1265459267
Name:SLADE, STACY N (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:N
Last Name:SLADE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:N
Other - Last Name:BIENKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1225 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2368
Mailing Address - Country:US
Mailing Address - Phone:231-935-0788
Mailing Address - Fax:231-935-0787
Practice Address - Street 1:1225 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2368
Practice Address - Country:US
Practice Address - Phone:231-935-0788
Practice Address - Fax:231-935-0787
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM28430Medicare ID - Type Unspecified