Provider Demographics
NPI:1972693638
Name:VIENHAGE, STACY A (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:VIENHAGE
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 1:3808 S. GREYSTONE CT.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-889-3332
Mailing Address - Fax:417-881-1410
Practice Address - Street 1:3808 S. GREYSTONE CT.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-889-3332
Practice Address - Fax:417-881-1410
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001029957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1940002Medicare PIN
MOP94811Medicare UPIN
13638002Medicare PIN
MO000085270Medicare PIN
MO000097041Medicare PIN