Provider Demographics
NPI:1336355999
Name:DAVIS, STACY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-4374
Mailing Address - Fax:515-643-2784
Practice Address - Street 1:5900 E UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PLEASANT HILL
Practice Address - State:IA
Practice Address - Zip Code:50327-8457
Practice Address - Country:US
Practice Address - Phone:515-643-2400
Practice Address - Fax:515-643-4766
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71945OtherWELLMARK BLUE SHIELD
IA001607OtherIOWA LICENSE
IA71945OtherWELLMARK BLUE SHIELD