Provider Demographics
NPI:1124075619
Name:MORITZ, STACIE L (PA-C)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:MORITZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:GRAF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4507
Mailing Address - Country:US
Mailing Address - Phone:701-712-4556
Mailing Address - Fax:701-712-4191
Practice Address - Street 1:1000 E ROSSER AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4414
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6430
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP00181243OtherMEDICARE RAILROAD
NDP80286Medicare UPIN
ND24594Medicare ID - Type Unspecified