Individual
STACY A WILLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1375 E 20TH AVE, DENVER, CO 80205-5422
(303) 338-4545
Mailing address
10350 E DAKOTA AVE, DENVER, CO 80247-1314
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0004027
CO
363A00000X
Physician Assistant
PA001171
ME
363A00000X
Physician Assistant
TL529
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
025301
KAISER COMMERCIAL NUMBER
CO
05
—
55381031
—
CO
Enumeration date
06/24/2009
Last updated
06/21/2021
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