Basic Information
| Provider Information | |||||||||
| NPI: | 1063421477 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | STACY | ||||||||
| FirstName: | ROBIN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX 665 | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755321 | ||||||||
| FaxNumber: | 5857306936 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853413015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 363L00000X | 333008 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207X00000X | 333008 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02396207 | 05 | NY | MEDICAID |