Provider Demographics
NPI:1447571385
Name:OLIVER, STACIE L (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:OLIVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:L
Other - Last Name:SANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 RED CLIFFS DR STE 4B
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-8170
Mailing Address - Country:US
Mailing Address - Phone:435-222-5527
Mailing Address - Fax:435-222-5529
Practice Address - Street 1:295 S 1470 E STE 102
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-1961
Practice Address - Country:US
Practice Address - Phone:435-222-5527
Practice Address - Fax:435-222-5529
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9233443-1205207LP2900X, 207LP2900X
OK27938207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1447571385Medicaid