Provider Demographics
NPI:1679054464
Name:CLUTTER, STACI LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LEIGH
Last Name:CLUTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:LEIGH
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1008 FLECK AVE
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-8738
Mailing Address - Country:US
Mailing Address - Phone:419-953-3910
Mailing Address - Fax:
Practice Address - Street 1:801 MEDICAL DR STE A
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-4030
Practice Address - Country:US
Practice Address - Phone:419-222-6622
Practice Address - Fax:419-224-0015
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant