Healthcare Provider Details

I. General information

NPI: 1629054895
Provider Name (Legal Business Name): STACY D MIERAU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY D HUNTER PA-C

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 OAK PARK BLVD STE 204
PISMO BEACH CA
93449-3400
US

IV. Provider business mailing address

921 OAK PARK BLVD STE 204
PISMO BEACH CA
93449-3400
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-4949
  • Fax: 805-473-3165
Mailing address:
  • Phone: 805-473-4949
  • Fax: 805-473-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: