Provider Demographics
NPI:1578809406
Name:STACK, TODD AARON (MMSC)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:AARON
Last Name:STACK
Suffix:
Gender:M
Credentials:MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 COUNTRY CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAD
Mailing Address - State:TX
Mailing Address - Zip Code:79701
Mailing Address - Country:US
Mailing Address - Phone:512-410-9650
Mailing Address - Fax:
Practice Address - Street 1:1180 W PECKHAM LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-5220
Practice Address - Country:US
Practice Address - Phone:512-410-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TX572271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant