Provider Demographics
NPI:1366824179
Name:VAN SAMBEEK, STACY LAMAE (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LAMAE
Last Name:VAN SAMBEEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LAMAE
Other - Last Name:BACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3200
Mailing Address - Fax:920-725-6535
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-725-0077
Practice Address - Fax:920-725-6535
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400230854Medicare Oscar/Certification
WIK400292177Medicare Oscar/Certification