Provider Demographics
NPI:1841274099
Name:BROWN, STACY S (PA-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:S
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14024 QUAIL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1006
Mailing Address - Country:US
Mailing Address - Phone:405-419-8465
Mailing Address - Fax:405-419-7745
Practice Address - Street 1:3115 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7901
Practice Address - Country:US
Practice Address - Phone:405-427-3705
Practice Address - Fax:405-427-3738
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100097540AMedicaid
OKP00878500OtherMEDICARE RAILROAD
P50686Medicare UPIN
OKOK402112Medicare PIN