MEDICARE: MS. JODY L STANTON PAC, 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
1	363A00000X	Physician Assistant	113614	MO

General Provider Information

NPI Number	:	1780684753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JODY L STANTON PAC, ATC

Provider Business Mailing Address
First Line	:	PO BOX 505673
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63150-5673
Country	:	US
Telephone Number	:	417-730-6430
Fax Number	:	417-269-7567

Provider Business Practice Location Address
First Line	:	3555 S NATIONAL AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-7310
Country	:	US
Telephone Number	:	--
Fax Number	:

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

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	10/04/2024

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