Provider Demographics
NPI:1366982621
Name:MCCOMAS, STACIE (NP-C)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:MCCOMAS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-2406
Mailing Address - Country:US
Mailing Address - Phone:208-420-2555
Mailing Address - Fax:
Practice Address - Street 1:476 CHENEY DR W
Practice Address - Street 2:SUITE 160
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3741
Practice Address - Country:US
Practice Address - Phone:208-944-0497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily