Provider Demographics
NPI:1821059908
Name:GARRY, STACEY LYNNE (MD)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNNE
Last Name:GARRY
Suffix:
Gender:F
Credentials:MD
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 98604
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8604
Mailing Address - Country:US
Mailing Address - Phone:702-732-3441
Mailing Address - Fax:702-732-2310
Practice Address - Street 1:3186 S MARYLAND PARKWAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109
Practice Address - Country:US
Practice Address - Phone:702-731-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6197207ZH0000X, 207ZP0102X
CAG86634207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002250HMedicaid
NV22WCGHS1KMedicare PIN
NV2002250HMedicaid