Provider Demographics
NPI:1609961788
Name:GOPAL, STACIE A (PA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:A
Last Name:GOPAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:A
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3000 STONEWOOD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8317
Mailing Address - Country:US
Mailing Address - Phone:724-934-5520
Mailing Address - Fax:724-934-5533
Practice Address - Street 1:3000 STONEWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8317
Practice Address - Country:US
Practice Address - Phone:724-934-5520
Practice Address - Fax:724-934-5533
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051198363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP81135Medicare UPIN