Provider Demographics
NPI:1578964102
Name:MAGUIRE, STACI MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:MARIE
Last Name:MAGUIRE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:MARIE
Other - Last Name:KRUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:#100
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-373-1222
Mailing Address - Fax:269-373-6270
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:#100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-373-1222
Practice Address - Fax:269-373-6270
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C97618Medicare PIN