Healthcare Provider Details

I. General information

NPI: 1518358894
Provider Name (Legal Business Name): STACEY ROOT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40601 N GANTZEL RD STE 103
SAN TAN VALLEY AZ
85140-7036
US

IV. Provider business mailing address

6451 N FEDERAL HWY STE 800
FORT LAUDERDALE FL
33308-1409
US

V. Phone/Fax

Practice location:
  • Phone: 602-648-5444
  • Fax: 602-772-3801
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8913
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7752
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8913
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number7752
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: