Provider Demographics
NPI:1346438157
Name:GUGINO, STACEY SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:SHANNON
Last Name:GUGINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 YOUNGS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8053
Mailing Address - Country:US
Mailing Address - Phone:716-636-7979
Mailing Address - Fax:
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8053
Practice Address - Country:US
Practice Address - Phone:716-636-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274288207Q00000X
NY012056-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine