Provider Demographics
NPI:1326224155
Name:PFANNENSTIEL, STACEY (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PFANNENSTIEL
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 1:2650 18TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211
Mailing Address - Country:US
Mailing Address - Phone:720-583-4470
Mailing Address - Fax:888-463-5887
Practice Address - Street 1:2650 18T ST
Practice Address - Street 2:STE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211
Practice Address - Country:US
Practice Address - Phone:720-583-4470
Practice Address - Fax:888-463-5887
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52739015Medicaid