Provider Demographics
NPI:1689783441
Name:STICKNEY, IRWIN (PA-C)
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:STICKNEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:IRV
Other - Middle Name:
Other - Last Name:STICKNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:4320 WORNALL RD
Mailing Address - Street 2:SUITE 50-II
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5941
Mailing Address - Country:US
Mailing Address - Phone:816-931-3312
Mailing Address - Fax:816-531-9862
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 50-II
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-931-3312
Practice Address - Fax:816-531-9862
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102536363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR22248Medicare UPIN