Provider Demographics
NPI:1316015910
Name:SHADIX, STACEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:SHADIX
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 1:2865 CHANCELLOR DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3912
Mailing Address - Country:US
Mailing Address - Phone:859-341-5400
Mailing Address - Fax:859-578-3172
Practice Address - Street 1:2865 CHANCELLOR DR
Practice Address - Street 2:SUITE 225
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3912
Practice Address - Country:US
Practice Address - Phone:859-341-5400
Practice Address - Fax:859-578-3172
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-2367363A00000X
KYPA1136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ56005Medicare UPIN