Provider Demographics
NPI:1972954345
Name:STASH, BRYCE DECIDUE (MD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:DECIDUE
Last Name:STASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 CHOUTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-3112
Mailing Address - Country:US
Mailing Address - Phone:325-660-4747
Mailing Address - Fax:
Practice Address - Street 1:1720 CHOUTEAU AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-3112
Practice Address - Country:US
Practice Address - Phone:325-660-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019983208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery