Provider Demographics
NPI:1790871093
Name:LAGARDE, STACIA GILDE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:GILDE MARIE
Last Name:LAGARDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4526
Mailing Address - Country:US
Mailing Address - Phone:616-965-8200
Mailing Address - Fax:616-742-9967
Practice Address - Street 1:200 S BOLTWOOD ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1926
Practice Address - Country:US
Practice Address - Phone:269-945-4220
Practice Address - Fax:269-945-4229
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301087952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4915234Medicaid