Provider Demographics
NPI:1891083713
Name:MINTER, STACEY M (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:M
Last Name:MINTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:MINTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:
Practice Address - Street 1:3506 KENNETT PIKE STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19807-3019
Practice Address - Country:US
Practice Address - Phone:302-661-3375
Practice Address - Fax:302-661-3374
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007592207V00000X
DEC2-0024392207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ425277Medicaid