Healthcare Provider Details

I. General information

NPI: 1043543473
Provider Name (Legal Business Name): STACY FULLER BAECKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DIVISADERO ST FL 4
SAN FRANCISCO CA
94143-3010
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 415-885-3882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21307
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1089187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: