Basic Information
| Provider Information | |||||||||
| NPI: | 1003029125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER-KELLY | ||||||||
| FirstName: | STACI | ||||||||
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| Credential: | RPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 HAMMOND LN | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129012000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185611322 | ||||||||
| FaxNumber: | 5185613420 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 HAMMOND LN | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129012000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185611322 | ||||||||
| FaxNumber: | 5185613420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008144 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MC1287829 | 01 | NY | DEA | OTHER |