Provider Demographics
NPI:1649242025
Name:OSTLER, STACY DIANE (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:DIANE
Last Name:OSTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:DIANE
Other - Last Name:SHOEMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-0434
Mailing Address - Country:US
Mailing Address - Phone:208-229-7075
Mailing Address - Fax:
Practice Address - Street 1:875 E PLAZA DR STE 103
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6549
Practice Address - Country:US
Practice Address - Phone:208-229-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA686852081P2900X
IDM-9953208100000X
WAMD000491702081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-9953OtherIDAHO MEDICAL LICENSE
IDM-9953OtherIDAHO MEDICAL LICENSE
H42077Medicare UPIN