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General NPI Number Information
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NPI Number | 1083376750
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Entity Type | Individual
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Provider Name | ILYA O STAGNER FNP-C
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Gender | Male
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Dates
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Enumeration Date | 10/11/2021
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 114 E SOUTH HILLS DR
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City | MARYVILLE
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State | MO
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Zip | 64468-2659
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Country | US
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Telephone | 660-562-4304
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Fax | 660-562-4308
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Provider Business Mailing Address
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Address Line | 114 E SOUTH HILLS DR
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City | MARYVILLE
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State | MO
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Zip | 64468-2659
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Country | US
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Telephone | 660-562-4304
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Fax | 660-562-4308
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 80603
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2024009165
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License Number State | MO
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