Provider Demographics
NPI:1801868062
Name:WALTON, STACEY MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIA
Last Name:WALTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 9TH AVE E
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-4738
Mailing Address - Country:US
Mailing Address - Phone:701-683-4711
Mailing Address - Fax:701-683-3205
Practice Address - Street 1:10 9TH AVE E
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4738
Practice Address - Country:US
Practice Address - Phone:701-683-4711
Practice Address - Fax:701-683-3205
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26331OtherBCBS ND
ND711669Medicare PIN
NDQ55512Medicare UPIN