Provider Demographics
NPI:1053430876
Name:PATTERSON, STACIE LYN (PA)
Entity type:Individual
Prefix:MS
First Name:STACIE
Middle Name:LYN
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:MERRITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:13677 W. MC DOWELL ROAD
Mailing Address - Street 2:STE 201
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395
Mailing Address - Country:US
Mailing Address - Phone:623-882-1926
Mailing Address - Fax:623-882-1709
Practice Address - Street 1:13677 W. MC DOWELL ROAD
Practice Address - Street 2:201
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-882-1926
Practice Address - Fax:623-882-1709
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004376363AM0700X
AZAZ 5154363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F37698OtherBCBSM
MI0F37698OtherBCBSM