Provider Demographics
NPI:1427126523
Name:OLIVIER, STACEY (PA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:OLIVIER
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 1:750 E BELTLINE AVE NE STE 301
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6046
Mailing Address - Country:US
Mailing Address - Phone:616-942-9343
Mailing Address - Fax:616-942-2538
Practice Address - Street 1:750 E BELTLINE AVE NE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6046
Practice Address - Country:US
Practice Address - Phone:616-942-9343
Practice Address - Fax:616-942-2538
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005064207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109586AMedicaid
GA202I977409Medicare PIN
GA003109586CMedicaid
GA003109586BMedicaid