Provider Demographics
NPI:1295722478
Name:SUMMA, STACY I (PA C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:I
Last Name:SUMMA
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:I
Other - Last Name:BUNTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE STE 110
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9291
Practice Address - Country:US
Practice Address - Phone:208-302-3200
Practice Address - Fax:208-302-3255
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16583363A00000X
IDPA-1787363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA16583AMedicare PIN