Provider Demographics
NPI:1326021734
Name:BOONE, STACY (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 N LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3025
Mailing Address - Country:US
Mailing Address - Phone:806-788-0040
Mailing Address - Fax:806-788-0015
Practice Address - Street 1:4802 N LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3025
Practice Address - Country:US
Practice Address - Phone:806-788-0040
Practice Address - Fax:806-788-0015
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX PA 00217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS64657Medicare UPIN
TXS64657Medicare UPIN