Provider Demographics
NPI:1730389958
Name:STASEY, JOHN PAUL
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PAUL
Last Name:STASEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICKEY
Other - Middle Name:
Other - Last Name:STASEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4413 PACK SADDLE PASS
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1623
Mailing Address - Country:US
Mailing Address - Phone:512-447-2333
Mailing Address - Fax:512-447-1717
Practice Address - Street 1:4413 PACK SADDLE PASS
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1623
Practice Address - Country:US
Practice Address - Phone:512-447-2333
Practice Address - Fax:512-447-1717
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0916960001OtherMEDICARE SUPPLIER NUMBER/