Provider Demographics
NPI:1184701567
Name:BEACH, STACY MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:BEACH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 SAN ALEJANDRO
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-7281
Mailing Address - Country:US
Mailing Address - Phone:956-605-2048
Mailing Address - Fax:
Practice Address - Street 1:1809 S CYNTHIA ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1111
Practice Address - Country:US
Practice Address - Phone:956-618-4402
Practice Address - Fax:956-618-4174
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2021-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP113892367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G1691Medicare ID - Type Unspecified