=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730123621
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACI LYN WARD PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 09/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1925 BUTTERFIELD TRL
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65345-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-564-4495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1925 BUTTERFIELD TRL
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65345-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-564-4495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA04077
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------