MEDICARE: STACY LANDERS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA61075846	WA
2	363A00000X	Physician Assistant	PA168821	OR
3	363AM0700X	Medical Physician Assistant	PA168821	OR

General Provider Information

NPI Number	:	1477973204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LANDERS PA-C

Provider Business Mailing Address
First Line	:	1840 E RAY RD
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85225-8720
Country	:	US
Telephone Number	:	855-397-0197
Fax Number	:	800-272-6512

Provider Business Practice Location Address
First Line	:	1547 NE 40TH AVE STE B
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1862
Country	:	US
Telephone Number	:	503-284-1937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2014
Last Update Date	:	07/29/2022

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Directions to “ STACY LANDERS PA-C” Practice Location

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