Provider Demographics
NPI:1326375536
Name:DELIDA, STACEY JULIA (PA)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:JULIA
Last Name:DELIDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:JULIA
Other - Last Name:GURCHIEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1865
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:248-898-1473
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant