MEDICARE: STACY L PURCELL P.A.

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	85002282	IL

General Provider Information

NPI Number	:	1952309981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY L PURCELL P.A.

Provider Business Mailing Address
First Line	:	123 W MICHIGAN ST
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-2028
Country	:	US
Telephone Number	:	815-791-9553
Fax Number	:	630-495-1770

Provider Business Practice Location Address
First Line	:	123 W MICHIGAN ST
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-2028
Country	:	US
Telephone Number	:	815-860-0757
Fax Number	:	708-923-2529

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	06/26/2019

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