Provider Demographics
NPI:1639711963
Name:LADOWITZ, STACI J (PA)
Entity Type:Individual
Prefix:MS
First Name:STACI
Middle Name:J
Last Name:LADOWITZ
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1418 CROSS ST
Mailing Address - Street 2:STE 160
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2988
Mailing Address - Country:US
Mailing Address - Phone:618-607-1320
Mailing Address - Fax:618-433-6492
Practice Address - Street 1:1418 CROSS ST
Practice Address - Street 2:STE 160
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:618-607-1320
Practice Address - Fax:618-433-6492
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2021-11-15
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Provider Licenses
StateLicense IDTaxonomies
IL085007299363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220076974Medicaid