Provider Demographics
NPI:1255621074
Name:HARR, STACEY L (PA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HARR
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 95000-4535
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:732-807-0800
Mailing Address - Fax:
Practice Address - Street 1:19 DAVIS AVE FL 4
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4488
Practice Address - Country:US
Practice Address - Phone:302-427-8329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003088L363A00000X
NJ25MP00546500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant