Provider Demographics
NPI:1922176643
Name:BISHOP, STACI FAYE (PAC)
Entity Type:Individual
Prefix:MS
First Name:STACI
Middle Name:FAYE
Last Name:BISHOP
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:STACI
Other - Middle Name:FAYE
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:373 EAST 10TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81073-0000
Mailing Address - Country:US
Mailing Address - Phone:719-523-6628
Mailing Address - Fax:719-523-4513
Practice Address - Street 1:373 EAST 10TH AVENUE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073-0000
Practice Address - Country:US
Practice Address - Phone:719-523-6628
Practice Address - Fax:719-523-4513
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07008493Medicaid