MEDICARE: DR. STACEY RAYBUCK

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	207Q00000X	Family Medicine Physician	008112	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720020076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY RAYBUCK

Provider Business Mailing Address
First Line	:	3250 N PIEDRA CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-0809
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 WESTPARK DR
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5031
Country	:	US
Telephone Number	:	910-310-4551
Fax Number	:

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

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	05/19/2023

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