Provider Demographics
NPI:1295734499
Name:SMITH, STACIA ANN (MD)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:ANN
Last Name:SMITH
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 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:1401 S LAVENTURE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-6033
Practice Address - Country:US
Practice Address - Phone:360-424-2400
Practice Address - Fax:360-424-2418
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029938207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA44444OtherLABOR AND INDUSTRIES
WA8148363Medicaid
WAAB05098Medicare ID - Type Unspecified
WA44444OtherLABOR AND INDUSTRIES