Provider Demographics
NPI:1821002502
Name:BOOTH, STACY B (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:B
Last Name:BOOTH
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:PO BOX 10583
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-435-2646
Practice Address - Fax:251-435-6478
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-472363AS0400X
ALPA.472363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-49995OtherBCBS
AL113211Medicaid
AL510-49993OtherBCBS
AL113213Medicaid
AL113243Medicaid
AL510-49994OtherBCBS
AL113209Medicaid
AL1821002502OtherTRICARE SOUTH
AL510-49992OtherBCBS
AL510-49995OtherBCBS
AL113213Medicaid