Provider Demographics
NPI:1255529012
Name:STUCKEY, LISA R (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:PA-C
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 99
Mailing Address - Street 2:
Mailing Address - City:KINSLEY
Mailing Address - State:KS
Mailing Address - Zip Code:67547-0099
Mailing Address - Country:US
Mailing Address - Phone:620-659-3651
Mailing Address - Fax:620-659-3869
Practice Address - Street 1:620 W 8TH ST
Practice Address - Street 2:
Practice Address - City:KINSLEY
Practice Address - State:KS
Practice Address - Zip Code:67547-2329
Practice Address - Country:US
Practice Address - Phone:620-659-3621
Practice Address - Fax:620-659-3810
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501228363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1255529012Medicare UPIN