Provider Demographics
NPI:1588289425
Name:STACY, SKYLAR P (MD)
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:P
Last Name:STACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 PETER PAN RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-7301
Mailing Address - Country:US
Mailing Address - Phone:620-577-4310
Mailing Address - Fax:620-577-4312
Practice Address - Street 1:510 PETER PAN RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-7301
Practice Address - Country:US
Practice Address - Phone:620-332-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-47487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program