Provider Demographics
NPI:1790733152
Name:PATTERSON, STACEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:A
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:49 N 8TH ST
Practice Address - Street 2:APT 5D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-2878
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2283862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00342433OtherRAILROAD MEDICARE
NY02634086Medicaid
NY05677NMedicare PIN
NYI23181Medicare UPIN
NY2EE7GYTXR1Medicare PIN
NY2637DHMedicare PIN
NY00250QMedicare PIN