Individual
KELSEY MARIE STACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
750 E ADAMS ST, SYRACUSE, NY 13210-2342
(315) 464-5136
Mailing address
2850 LAFAYETTE RD, LA FAYETTE, NY 13084-9529
(315) 677-8081
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
262832
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03428026
—
NY
Enumeration date
05/19/2009
Last updated
08/31/2012
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