Provider Demographics
NPI:1033240833
Name:LAGOMARSINO, STACY M (PAC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:LAGOMARSINO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:GARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9718
Mailing Address - Country:US
Mailing Address - Phone:209-735-6102
Mailing Address - Fax:
Practice Address - Street 1:1600 OWENS ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2261
Practice Address - Country:US
Practice Address - Phone:415-833-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18133363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical