Basic Information
| Provider Information | |||||||||
| NPI: | 1881702298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORRESTT | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STATLER | ||||||||
| OtherFirstName: | STACY | ||||||||
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| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 411895 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641411895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136322230 | ||||||||
| FaxNumber: | 9136322297 | ||||||||
| Practice Location | |||||||||
| Address1: | 9100 W. 74TH STREET | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136762679 | ||||||||
| FaxNumber: | 9137893191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA003020L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 1501310 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42508017 | 01 | KS | BCBS KC | OTHER | 200623680A | 05 | KS | MEDICAID | P00765509 | 01 | KS | RR MEDICARE | OTHER |