Provider Demographics
NPI:1942389408
Name:CAMPBELL, STACEY M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:M
Last Name:CAMPBELL
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:PO BOX 3390
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 MAY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1526
Practice Address - Country:US
Practice Address - Phone:541-387-1300
Practice Address - Fax:541-386-6224
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004739363A00000X
ORPA01196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00630499OtherRR MEDICARE (PH&S)-PMG
OR500600089Medicaid
WA8416539Medicaid
WA0142139OtherWA STATE D L&I NUMBER
WA8416539Medicaid
ORR151239Medicare PIN
ORR150440Medicare PIN
WAQ38254Medicare UPIN
ORR138430Medicare PIN
ORR150640Medicare PIN
WA0142139OtherWA STATE D L&I NUMBER
ORP00630499OtherRR MEDICARE (PH&S)-PMG