Provider Demographics
NPI:1982154548
Name:MCFADDEN, STACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MCFADDEN
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 1:4341 BOUGAINVILLA DR
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE BY THE SEA
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5017
Mailing Address - Country:US
Mailing Address - Phone:954-492-8866
Mailing Address - Fax:954-337-8180
Practice Address - Street 1:1117 E HALLANDALE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4488
Practice Address - Country:US
Practice Address - Phone:954-454-6300
Practice Address - Fax:954-241-6908
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109862363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9109862OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH