Provider Demographics
NPI:1902101231
Name:HOOD, STACEY (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:WALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:104 UNION AVE STE 806
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1844
Mailing Address - Country:US
Mailing Address - Phone:315-423-7192
Mailing Address - Fax:315-423-8013
Practice Address - Street 1:104 UNION AVE STE 806
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1844
Practice Address - Country:US
Practice Address - Phone:315-423-7192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA054789363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant