Provider Demographics
NPI:1568816528
Name:MANROE, STACY L (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:MANROE
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 1:695 US HIGHWAY 46
Mailing Address - Street 2:SUITE 400A
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1592
Mailing Address - Country:US
Mailing Address - Phone:973-894-1263
Mailing Address - Fax:888-972-3703
Practice Address - Street 1:3897 CAMERON DR NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3888
Practice Address - Country:US
Practice Address - Phone:973-826-8080
Practice Address - Fax:866-309-3354
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003512363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8955106Medicare PIN