Provider Demographics
NPI:1629054895
Name:MIERAU, STACY D (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:D
Last Name:MIERAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:D
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:921 OAK PARK BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3400
Mailing Address - Country:US
Mailing Address - Phone:805-473-4949
Mailing Address - Fax:805-473-3165
Practice Address - Street 1:921 OAK PARK BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3400
Practice Address - Country:US
Practice Address - Phone:805-473-4949
Practice Address - Fax:805-473-3165
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500085Medicaid
NV100500085Medicaid
NVV39850Medicare ID - Type Unspecified