Basic Information
| Provider Information | |||||||||
| NPI: | 1215217096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PILKINGTON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEASTROM | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5365 SPINE RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803013324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035309325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5365 SPINE RD STE C | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803013324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035309325 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | UO2794 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 207N00000X | DR.0054787 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | DR.0054787 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 31507832 | 05 | CO | MEDICAID |