Provider Demographics
NPI:1790228765
Name:BROWN, STACY (PA)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MOSSBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1263 LAKE PLAZA DR STE 120
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3510
Mailing Address - Country:US
Mailing Address - Phone:719-776-3330
Mailing Address - Fax:719-776-3349
Practice Address - Street 1:1263 LAKE PLAZA DR STE 120
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3510
Practice Address - Country:US
Practice Address - Phone:719-776-3330
Practice Address - Fax:719-776-3349
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006643363A00000X, 363AM0700X
GA008199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000190983Medicaid