Provider Demographics
NPI:1629170592
Name:STACK, JOHN DAVID (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:STACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-532-8584
Mailing Address - Fax:530-532-8433
Practice Address - Street 1:1611 FEATHER RIVER BLVD
Practice Address - Street 2:SUITE #10
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:98685
Practice Address - Country:US
Practice Address - Phone:530-534-4530
Practice Address - Fax:530-532-8290
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q17918Medicare UPIN
CAOPA136830Medicare ID - Type Unspecified