Provider Demographics
NPI:1821059692
Name:KO, STACEY L (PA-C)
Entity Type:Individual
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First Name:STACEY
Middle Name:L
Last Name:KO
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:651-415-4101
Practice Address - Street 1:7500 80TH ST S, SUITE 100 - MS 34624A
Practice Address - Street 2:HEALTHPARTNERS COTTAGE GROVE CLINIC
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-3008
Practice Address - Country:US
Practice Address - Phone:651-415-4100
Practice Address - Fax:651-415-4101
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-03-11
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Provider Licenses
StateLicense IDTaxonomies
MN9655363A00000X
MNP-474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN150112700Medicaid
P48684Medicare UPIN
MN150112700Medicaid