Provider Demographics
NPI:1720020076
Name:RAYBUCK, STACEY
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:RAYBUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 N PIEDRA CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-0809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WESTPARK DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5031
Practice Address - Country:US
Practice Address - Phone:910-310-4551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008112207Q00000X, 207Q00000X
PAOS012808207Q00000X, 2083P0011X
UT6947119-12042083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ767741Medicaid
PA102413281Medicaid
AZ104697Medicare ID - Type Unspecified
AZ767741Medicaid
PA173300Medicare PIN