Provider Demographics
NPI:1508960832
Name:LUSBY, STACIA W (MD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:W
Last Name:LUSBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 BRIGHTON PL
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-4909
Mailing Address - Country:US
Mailing Address - Phone:806-353-2645
Mailing Address - Fax:
Practice Address - Street 1:1501 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1770
Practice Address - Country:US
Practice Address - Phone:806-367-2488
Practice Address - Fax:806-354-1833
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL61032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184947303Medicaid
TX184947303Medicaid