Provider Demographics
NPI:1962486969
Name:KONZAK, STACEY LEE (PA C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:KONZAK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LEE
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5713 80TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-9657
Mailing Address - Country:US
Mailing Address - Phone:701-303-0263
Mailing Address - Fax:701-395-4456
Practice Address - Street 1:2900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-5112
Practice Address - Country:US
Practice Address - Phone:701-221-9997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0537363A00000X
NDPAC0348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6825030Medicaid
ND71237Medicaid
S41495Medicare ID - Type Unspecified
ND71237Medicaid