MEDICARE: STACIE A GILROY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	726	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	470834610	OTHER		TAX IDENIFICATION NUMBER

General Provider Information

NPI Number	:	1619906864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE A GILROY

Provider Business Mailing Address
First Line	:	249 OLSON DRIVE
Second Line	:	SUITE 111
City	:	PAPILLION
State	:	NE
Zip	:	68046-2974
Country	:	US
Telephone Number	:	402-991-2200
Fax Number	:	402-991-2242

Provider Business Practice Location Address
First Line	:	249 OLSON DRIVE
Second Line	:	SUITE 111
City	:	PAPILLION
State	:	NE
Zip	:	68046-2974
Country	:	US
Telephone Number	:	402-991-2200
Fax Number	:	402-991-2242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	03/07/2023

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Directions to “ STACIE A GILROY ” Practice Location

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