Healthcare Provider Details

I. General information

NPI: 1154782498
Provider Name (Legal Business Name): PAMELA STASO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473
US

IV. Provider business mailing address

23732 RISEN RD
WAYNESVILLE MO
65583-2506
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000159
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: