Provider Demographics
NPI:1891102455
Name:GLEIM, STACEY LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:GLEIM
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 1:3450 HULL ROAD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32611-2727
Mailing Address - Country:US
Mailing Address - Phone:352-273-7374
Mailing Address - Fax:
Practice Address - Street 1:3450 HULL ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32611-2727
Practice Address - Country:US
Practice Address - Phone:352-273-7374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107985363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012976400Medicaid
FLHX430ZMedicare PIN