Provider Demographics
NPI:1902423890
Name:SASSAMAN, STACEY DIANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:DIANNE
Last Name:SASSAMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 SPRING GARDEN ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-5008
Mailing Address - Country:US
Mailing Address - Phone:570-765-1494
Mailing Address - Fax:
Practice Address - Street 1:10 SHURS LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-2123
Practice Address - Country:US
Practice Address - Phone:215-967-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT221915207Q00000X
PA00000000000000000000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine