Provider Demographics
NPI:1275054322
Name:RYDELL, STACIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:RYDELL
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 1:2961 MOSSROCK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5119
Mailing Address - Country:US
Mailing Address - Phone:210-731-4800
Mailing Address - Fax:210-731-4886
Practice Address - Street 1:8906 PERRIN BEITEL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-572-3306
Practice Address - Fax:210-249-0125
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant