Provider Demographics
NPI:1932199072
Name:ERSTAD, STACY (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ERSTAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 WHITEWATER WAY
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:MN
Mailing Address - Zip Code:55932-9737
Mailing Address - Country:US
Mailing Address - Phone:507-876-0115
Mailing Address - Fax:
Practice Address - Street 1:515 WHITEWATER WAY
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:MN
Practice Address - Zip Code:55932-9737
Practice Address - Country:US
Practice Address - Phone:507-876-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP76802Medicare UPIN