Provider Demographics
NPI:1881702298
Name:FORRESTT, STACY A (PAC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:FORRESTT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:STATLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 411895
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1895
Mailing Address - Country:US
Mailing Address - Phone:913-632-2230
Mailing Address - Fax:913-632-2297
Practice Address - Street 1:9100 W. 74TH STREET
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-676-2679
Practice Address - Fax:913-789-3191
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003020L363AM0700X
KS1501310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS42508017OtherBCBS KC
KS200623680AMedicaid
KSP00765509OtherRR MEDICARE