Provider Demographics
NPI:1922089234
Name:JAMES, STACEY G (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:G
Last Name:JAMES
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:PO BOX 2549
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92690-0549
Mailing Address - Country:US
Mailing Address - Phone:949-462-0560
Mailing Address - Fax:
Practice Address - Street 1:24902 MOULTON PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92637-6410
Practice Address - Country:US
Practice Address - Phone:949-462-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15225OtherMEDICARE PTAN #
CA1982635322OtherGROUP NPI #
CAQ54190Medicare UPIN
CAW15225OtherMEDICARE PTAN #