Provider Demographics
NPI:1477973204
Name:LANDERS, STACY (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LANDERS
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 1:1840 E RAY RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:855-397-0197
Mailing Address - Fax:800-272-6512
Practice Address - Street 1:1547 NE 40TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1862
Practice Address - Country:US
Practice Address - Phone:503-284-1937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-19
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61075846363AM0700X
ORPA168821363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical