Provider Demographics
NPI:1932754132
Name:STUBBLEFIELD, BRADY (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:STUBBLEFIELD
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 1:456 N NEW BALLAS RD STE 118
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6812
Mailing Address - Country:US
Mailing Address - Phone:314-567-1400
Mailing Address - Fax:314-567-9559
Practice Address - Street 1:915 E MARKET AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72149-5615
Practice Address - Country:US
Practice Address - Phone:501-279-5642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2023006828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program