Provider Demographics
NPI:1619942331
Name:WINTERS, STACEY LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LEIGH
Last Name:WINTERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6255
Mailing Address - Country:US
Mailing Address - Phone:971-287-5111
Mailing Address - Fax:503-472-0127
Practice Address - Street 1:2700 SE STRATUS AVE UNIT 405
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6258
Practice Address - Country:US
Practice Address - Phone:971-287-5111
Practice Address - Fax:503-472-0127
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60176915208000000X
ORDO173291208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1619942331Medicaid
WA025904OtherKRMC L&I GROUP NUMBER