Provider Demographics
NPI:1346454212
Name:SKIANO, STACIE CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:CHRISTINE
Last Name:SKIANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STACIE
Other - Middle Name:CHRISTINE
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:702 S. EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067
Mailing Address - Country:US
Mailing Address - Phone:734-776-9183
Mailing Address - Fax:513-569-5297
Practice Address - Street 1:350 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-457-1386
Practice Address - Fax:513-569-5297
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005145RX363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M08420028Medicare PIN
MI0767220001OtherADMINISTAR FEDERAL
MI2056316730OtherBCBS PIN
MI0F33583OtherBCBS DME
MI0M08420028Medicare PIN