Provider Demographics
NPI:1760549919
Name:BASQUIN, STACEY (PAC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BASQUIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1640
Mailing Address - Country:US
Mailing Address - Phone:912-681-4911
Mailing Address - Fax:912-681-6911
Practice Address - Street 1:1601 FAIR ROAD
Practice Address - Street 2:SUITE 600 COTTON RIDGE MEDICAL PLAZA
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-681-4911
Practice Address - Fax:912-681-6911
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4104GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP93757Medicare UPIN