Provider Demographics
NPI:1225391113
Name:BHALODI, STACI (PA-C)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BHALODI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 TATES CREEK ROAD
Mailing Address - Street 2:APT 4415
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517
Mailing Address - Country:US
Mailing Address - Phone:718-594-3826
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:C225
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0293
Practice Address - Country:US
Practice Address - Phone:859-323-6602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-17
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2120363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA2120OtherLICENSE