Basic Information
| Provider Information | |||||||||
| NPI: | 1316291479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOPPER | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10900 W 44TH AVE UNIT 200 | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039931330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10900 W 44TH AVE UNIT 200 | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039931330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2012 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP4949 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 12199 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 2429 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | Z171648 | 01 | AZ | PTAN | OTHER | 829176 | 05 | AZ | MEDICAID |