Provider Demographics
NPI:1922073527
Name:KOFMAN, STACEY R (ATC, PTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:KOFMAN
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:49 SHOWERS DR
Mailing Address - Street 2:J324
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-1463
Mailing Address - Country:US
Mailing Address - Phone:650-949-4561
Mailing Address - Fax:
Practice Address - Street 1:50 EMBARCADERO RD
Practice Address - Street 2:PALO ALTO HIGH SCHOOL
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2321
Practice Address - Country:US
Practice Address - Phone:650-329-3892
Practice Address - Fax:650-566-0612
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer