Provider Demographics
NPI:1780684753
Name:STANTON, JODY L (PAC, ATC)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:L
Last Name:STANTON
Suffix:
Gender:F
Credentials:PAC, ATC
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 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:1601 BRANSON HILLS PKWY STE 120
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-9908
Practice Address - Country:US
Practice Address - Phone:417-335-7555
Practice Address - Fax:417-335-7529
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113614363A00000X, 363A00000X
FLAL1905247200000X
FLPA9103016363AS0400X
GA4300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131625AMedicaid
FL292102200Medicaid
GA202I979022Medicare PIN
GA003131625AMedicaid