Provider Demographics
NPI:1417399585
Name:BOGDANOWICZ, STACEY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BOGDANOWICZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2185
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2185
Mailing Address - Country:US
Mailing Address - Phone:509-474-6842
Mailing Address - Fax:509-474-6606
Practice Address - Street 1:715 S COWLEY ST STE 210
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202
Practice Address - Country:US
Practice Address - Phone:509-473-6706
Practice Address - Fax:509-473-6704
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23097363A00000X
WAPA60449258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034728Medicaid
OR500669258Medicaid