Provider Demographics
NPI:1730123621
Name:WARD, STACI LYN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LYN
Last Name:WARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:STACI
Other - Middle Name:LYN
Other - Last Name:BRANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1925 BUTTERFIELD TRL
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MO
Mailing Address - Zip Code:65345-2814
Mailing Address - Country:US
Mailing Address - Phone:817-564-4495
Mailing Address - Fax:
Practice Address - Street 1:1925 BUTTERFIELD TRL
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MO
Practice Address - Zip Code:65345-2814
Practice Address - Country:US
Practice Address - Phone:817-564-4495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04077363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1164467692OtherMEDICARE GROUP NPI
TX00178VMedicare PIN
S59610Medicare UPIN