Provider Demographics
NPI:1619286382
Name:ROSE, STACY A (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:ROSE
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 1:800 W CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2349
Mailing Address - Country:US
Mailing Address - Phone:847-618-3040
Mailing Address - Fax:
Practice Address - Street 1:800 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2349
Practice Address - Country:US
Practice Address - Phone:847-618-3040
Practice Address - Fax:847-618-3049
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003858OtherSTATE LICENSE