Provider Demographics
NPI:1063421477
Name:STACY, ROBIN (NP)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 665
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-5321
Mailing Address - Fax:585-730-6936
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 655
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-341-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333008363L00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02396207Medicaid
NYRA5622Medicare PIN
NYP22743Medicare UPIN
NYCC4107Medicare PIN