Healthcare Provider Details

I. General information

NPI: 1982154548
Provider Name (Legal Business Name): STACEY MCFADDEN P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E HALLANDALE BEACH BLVD
HALLANDALE BEACH FL
33009-4488
US

IV. Provider business mailing address

4341 BOUGAINVILLA DR
LAUDERDALE BY THE SEA FL
33308-5017
US

V. Phone/Fax

Practice location:
  • Phone: 954-454-6300
  • Fax: 954-241-6908
Mailing address:
  • Phone: 954-492-8866
  • Fax: 954-337-8180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9109862
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: