Provider Demographics
NPI:1609805191
Name:COCKE, STACIE MADELINE (PA)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:MADELINE
Last Name:COCKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:GEER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-0469
Mailing Address - Fax:484-884-0628
Practice Address - Street 1:5074 KERNSVILLE RD
Practice Address - Street 2:
Practice Address - City:OREFIELD
Practice Address - State:PA
Practice Address - Zip Code:18069-2350
Practice Address - Country:US
Practice Address - Phone:610-395-1993
Practice Address - Fax:610-395-2516
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI03894363A00000X
MI5601003894363A00000X
PAMA059210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P08280Medicare ID - Type Unspecified
MI68186Medicare UPIN