Basic Information
| Provider Information | |||||||||
| NPI: | 1982154548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCFADDEN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4341 BOUGAINVILLA DR | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE BY THE SEA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333085017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544928866 | ||||||||
| FaxNumber: | 9543378180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 E HALLANDALE BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | HALLANDALE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330094488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544546300 | ||||||||
| FaxNumber: | 9542416908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2016 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9109862 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA9109862 | 01 | FL | STATE OF FLORIDA DEPARTMENT OF HEALTH | OTHER |