Healthcare Provider Details

I. General information

NPI: 1235393851
Provider Name (Legal Business Name): STACY M KIRBY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2008
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 - 1ST AVE SE SUITE 200
CEDAR RAPIDS IA
52402-5417
US

IV. Provider business mailing address

1815 - 1ST AVE SE SUITE 200
CEDAR RAPIDS IA
52402-5417
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-0474
  • Fax: 319-363-2170
Mailing address:
  • Phone: 319-363-0474
  • Fax: 319-363-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number001929
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1962610725
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: