Provider Demographics
NPI:1659937456
Name:LOCICERO, STEPHANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LOCICERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:866-617-6855
Mailing Address - Fax:503-346-8015
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-6594
Practice Address - Fax:503-494-4285
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23973207R00000X
363A00000X
ORPA213429363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant