Provider Demographics
NPI:1649272410
Name:FORST, STACY L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:L
Last Name:FORST
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 1:2 FALLING WATER LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4498
Mailing Address - Country:US
Mailing Address - Phone:260-417-1245
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-598-6984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV1617363AM0700X
IN10000517A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN055770TMedicare PIN
INP42982Medicare UPIN