Provider Demographics
NPI:1427096783
Name:STACY, DAVID THOMAS (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:STACY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 EMBARCADERO W
Mailing Address - Street 2:APT 4319
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-3719
Mailing Address - Country:US
Mailing Address - Phone:510-282-1335
Mailing Address - Fax:
Practice Address - Street 1:3161 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2216
Practice Address - Country:US
Practice Address - Phone:510-796-1000
Practice Address - Fax:510-796-1050
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ63146Medicare UPIN