Provider Demographics
NPI:1265789945
Name:LI, STACY W (R-PAC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:W
Last Name:LI
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 KISSENA BLVD STE 5A
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3105
Mailing Address - Country:US
Mailing Address - Phone:718-886-9000
Mailing Address - Fax:
Practice Address - Street 1:4012 80TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1234
Practice Address - Country:US
Practice Address - Phone:718-886-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015855363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical