Healthcare Provider Details

I. General information

NPI: 1164781381
Provider Name (Legal Business Name): STACY ELAINE NEUDORF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY ELAINE ALLEN PA-C

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 22ND PL
LUBBOCK TX
79410-1119
US

IV. Provider business mailing address

3420 22ND PL
LUBBOCK TX
79410-1314
US

V. Phone/Fax

Practice location:
  • Phone: 806-725-0030
  • Fax: 806-725-0015
Mailing address:
  • Phone: 806-725-5844
  • Fax: 806-723-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10708
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: