Provider Demographics
NPI:1487447538
Name:STACK, COREY ALEXANDER (PA)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:ALEXANDER
Last Name:STACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:480 ABERDEEN RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1023
Mailing Address - Country:US
Mailing Address - Phone:830-563-7390
Mailing Address - Fax:
Practice Address - Street 1:5801 S TRANSIT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5811
Practice Address - Country:US
Practice Address - Phone:716-727-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant