Provider Demographics
NPI:1972517100
Name:ALEXANDER, STACY A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:A
Last Name:ALEXANDER
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 1:405 N BAILEY MAE CT
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67147-4011
Mailing Address - Country:US
Mailing Address - Phone:316-744-7924
Mailing Address - Fax:316-259-1972
Practice Address - Street 1:6100 E CENTRAL AVE STE 3
Practice Address - Street 2:STE 101
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4237
Practice Address - Country:US
Practice Address - Phone:316-689-5235
Practice Address - Fax:316-691-6788
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
110173325OtherMEDICARE - VCPG
110999006OtherMEDICARE - WT MGMT
KS1500973OtherLICENSE
KS110990023Medicare PIN
KSQ22981Medicare UPIN
KS200266460EMedicaid