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NPI Code Detail

MEDICARE: STACEY ROOT PA-C, ATC

MEDICARE: STACEY ROOT PA-C, ATC
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
12255A2300XAthletic Trainer
2363AS0400XSurgical Physician Assistant8913AZ
3363A00000XPhysician Assistant8913AZ

General Provider Information

NPI Number : 1518358894
Entity Type Code : Individual
Provider Name (Legal Business Name) : STACEY ROOT PA-C, ATC
Provider Business Mailing Address
First Line : 25408 S 197TH ST
Second Line :
City : QUEEN CREEK
State : AZ
Zip : 85142-8992
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 40601 N GANTZEL RD STE 103
Second Line :
City : SAN TAN VALLEY
State : AZ
Zip : 85140-7036
Country : US
Telephone Number : 602-648-5444
Fax Number : 602-772-3801
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/09/2015
Last Update Date : 03/11/2024

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Directions to “ STACEY ROOT PA-C, ATC” Practice Location

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