Provider Demographics
NPI:1851354427
Name:SCROGGINS, STACY LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:LYNN
Last Name:SCROGGINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E. OKLAHOMA
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501
Mailing Address - Country:US
Mailing Address - Phone:918-423-4900
Mailing Address - Fax:918-423-4905
Practice Address - Street 1:101 E. OKLAHOMA
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501
Practice Address - Country:US
Practice Address - Phone:918-423-4900
Practice Address - Fax:918-423-4905
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1066363A00000X
OKPA1066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100228530AMedicaid
100739490NOtherSOONER CARE PCP
OK100228530AMedicaid
100739490NOtherSOONER CARE PCP
OKP25480Medicare UPIN