| NPI | 1972743185 |
|---|---|
| Former Name | STACEY RENEE MOOSE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103070) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110003000) |
| Enumeration Date | 2009-02-27 |
| Last Update Date | 2020-10-28 |