Healthcare Provider Details

I. General information

NPI: 1013193556
Provider Name (Legal Business Name): STACIE MARIE FULCHER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACIE MARIE KOCHIER

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 06/20/2024
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 NW ELKS DRIVE
CORVALLIS OR
97330
US

IV. Provider business mailing address

444 NW ELKS DRIVE
CORVALLIS OR
97330
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1256
  • Fax: 360-597-1472
Mailing address:
  • Phone: 541-754-1256
  • Fax: 360-597-1472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1014
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA154004
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA154004
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: