Provider Demographics
NPI:1720367873
Name:STAMPS, ROSLYN ALISIA (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSLYN
Middle Name:ALISIA
Last Name:STAMPS
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 1:6777 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:248-661-6425
Mailing Address - Fax:
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-664-1642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005275363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1156323890OtherBCBS IND
MIP0930014Medicare PIN