Provider Demographics
NPI:1790835932
Name:BOOMER, STACEY NOEL (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:NOEL
Last Name:BOOMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:NOEL
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:322 W NORTH RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-3208
Mailing Address - Country:US
Mailing Address - Phone:509-324-6464
Mailing Address - Fax:509-241-2056
Practice Address - Street 1:322 W NORTH RIVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3208
Practice Address - Country:US
Practice Address - Phone:509-324-6464
Practice Address - Fax:509-241-2056
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant