Provider Demographics
NPI:1790754364
Name:RILEY, STACEY M (PA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:RILEY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 MARSH BROOK DR STE 205
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-6523
Practice Address - Country:US
Practice Address - Phone:603-742-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3079348Medicaid
0010552Medicare PIN