Basic Information
| Provider Information | |||||||||
| NPI: | 1083632913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARS | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11811 NE 128TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980347200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258213472 | ||||||||
| FaxNumber: | 4258204115 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 116TH AVE NE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252501145 | ||||||||
| FaxNumber: | 4258236028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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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 | 2085R0202X | MD00037017 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8263188 | 05 | WA | MEDICAID |