Provider Demographics
NPI:1689784837
Name:MURRAY, STACIE R (PAC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:MURRAY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:R
Other - Last Name:LEHTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7989
Practice Address - Street 1:106 S SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:DAGGETT
Practice Address - State:MI
Practice Address - Zip Code:49821
Practice Address - Country:US
Practice Address - Phone:906-753-2155
Practice Address - Fax:906-753-2716
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1117363A00000X
MI5601005068363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1031550OtherNATIONAL COMMISSION ON CERTIFIED PHYSICIANS ASSISTANTS
WI42982000Medicaid
MI0N41200012OtherMICHIGAN MEDICARE
S84046Medicare UPIN
MI000017Medicare Oscar/Certification
WI42982000Medicare Oscar/Certification
MI0N41200012OtherMICHIGAN MEDICARE
WI42982000Medicaid