Healthcare Provider Details

I. General information

NPI: 1205027620
Provider Name (Legal Business Name): STACEY BISPHAM ROYCE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY E BISPHAM PA

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 21ST AVE W
BRADENTON FL
34209-7847
US

IV. Provider business mailing address

6001 21ST AVE W
BRADENTON FL
34209-7847
US

V. Phone/Fax

Practice location:
  • Phone: 941-761-4448
  • Fax: 941-761-0235
Mailing address:
  • Phone: 941-761-4448
  • Fax: 941-761-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104208
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: