Provider Demographics
NPI:1437339702
Name:ROTZ, STACEY LAVON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LAVON
Last Name:ROTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SIR THOMAS CT FL 1
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-988-0020
Mailing Address - Fax:717-703-5746
Practice Address - Street 1:805 SIR THOMAS CT FL 1
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-988-0020
Practice Address - Fax:717-703-5746
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103176510Medicaid