Provider Demographics
NPI:1184071680
Name:WOODS, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WOODS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 702
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-0702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1585 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4345
Practice Address - Country:US
Practice Address - Phone:503-589-0463
Practice Address - Fax:503-589-0463
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical