Provider Demographics
NPI:1649213133
Name:MCCARRON, STACY L (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:MCCARRON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:616-389-1766
Practice Address - Street 1:145 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2562
Practice Address - Country:US
Practice Address - Phone:616-954-9800
Practice Address - Fax:616-954-2116
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211661363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01012712OtherRR MEDICARE
MI1649213133Medicaid
MI1649213133Medicaid
MIP01012712OtherRR MEDICARE
MI0M08620038Medicare PIN