Provider Demographics
NPI:1013193556
Name:FULCHER, STACIE MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:STACIE
Middle Name:MARIE
Last Name:FULCHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:MARIE
Other - Last Name:KOCHIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:444 NW ELKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-754-1256
Mailing Address - Fax:360-597-1472
Practice Address - Street 1:444 NW ELKS DRIVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-754-1256
Practice Address - Fax:360-597-1472
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1014363A00000X
ORPA154004363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500642760Medicaid