Provider Demographics
NPI:1770842452
Name:BRINK, STACIA (PA-C)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:BRINK
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 1:7710 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2320
Mailing Address - Country:US
Mailing Address - Phone:772-335-5300
Mailing Address - Fax:772-878-7602
Practice Address - Street 1:7710 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2320
Practice Address - Country:US
Practice Address - Phone:772-335-5300
Practice Address - Fax:772-878-7602
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0AK5OtherBCBS
FLGF027ZMedicare PIN