Provider Demographics
NPI:1487676235
Name:GILL, STACIE SUZANNE (DPM)
Entity Type:Individual
Prefix:MISS
First Name:STACIE
Middle Name:SUZANNE
Last Name:GILL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 S QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-4941
Mailing Address - Country:US
Mailing Address - Phone:717-718-5511
Mailing Address - Fax:717-718-0660
Practice Address - Street 1:2410 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4941
Practice Address - Country:US
Practice Address - Phone:717-718-5511
Practice Address - Fax:717-718-0660
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005723213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
50043518OtherCAPITOL BLUE CROSS
072356VKJMedicare PIN
50043518OtherCAPITOL BLUE CROSS