Provider Demographics
NPI:1417930199
Name:FERGUSON, STACY (PTA, AA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PTA, AA
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 829
Mailing Address - Street 2:
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326-0829
Mailing Address - Country:US
Mailing Address - Phone:509-234-2021
Mailing Address - Fax:509-234-9200
Practice Address - Street 1:1100 W CLARK RD
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326-9700
Practice Address - Country:US
Practice Address - Phone:509-234-2021
Practice Address - Fax:509-234-9200
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60040866225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP1 60040866OtherPHYSICAL THERAPY ASSISTANT