Provider Demographics
NPI:1639155740
Name:MCILROY, STACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MCILROY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:ANGULO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22 CORPORATE PLAZA DR.
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-722-5017
Mailing Address - Fax:949-432-3354
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-7038
Practice Address - Fax:949-630-4900
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2272363AS0400X
CA53563363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ486549Medicaid
AZP00021617OtherRAILROAD MEDICARE
AZ86080015085259C297OtherTRIWEST
AZZ71697Medicare PIN
AZ86080015085259C297OtherTRIWEST