Provider Demographics
NPI:1245816776
Name:STACY, MARCUS STEVEN
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:STEVEN
Last Name:STACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 14TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-3423
Mailing Address - Country:US
Mailing Address - Phone:918-533-7454
Mailing Address - Fax:
Practice Address - Street 1:1001 E 18TH ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2907
Practice Address - Country:US
Practice Address - Phone:918-786-2243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant