Provider Demographics
NPI:1437429388
Name:SHIMANEK, STACIA KRISTINE (PA)
Entity Type:Individual
Prefix:MRS
First Name:STACIA
Middle Name:KRISTINE
Last Name:SHIMANEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:
Other - Last Name:SUNDERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1640 OLD PECOS TRL STE H
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4777
Mailing Address - Country:US
Mailing Address - Phone:505-992-0233
Mailing Address - Fax:505-992-0609
Practice Address - Street 1:200 COMMONS WAY STE B
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1915
Practice Address - Country:US
Practice Address - Phone:406-752-5170
Practice Address - Fax:406-752-5210
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NMPA2019-0026363A00000X
MTMED-PAC-LIC-113123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX869N70OtherBCBSTX
TXTXB146546Medicare PIN