Stacie Henderson, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

13182462-1206 Issued in UT

Practice address

972 N 600 E
Spanish Fork, UT 84660-1306

Phone

(801) 465-4896

Fax

(801) 465-3267

NPI assigned

May 11, 2021

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Stacie Rene de Jesus Henderson Other name

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

University of Utah School of Medicine, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Revere Health PCGroup PAC ID 7517868508, 407 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: staciehenderson@cuccu.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Revere Health PC

  • Multi-Specialty Clinic/Center
  • Provo, UT
  • NPI 1093764805
  Medicare reassignment Care Compare group NPD
• Revere Health PC

  • Multi-Specialty Clinic/Center
  • Spanish Fork, UT
  • NPI 1851142285
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1620691200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678320000000",
    "number": "1982288486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1055 N 500 W",
            "address_2": "ATTN. CREDENTIALING",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846043305",
            "telephone_number": "801-354-8225",
            "fax_number": "801-418-0941"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "972 N 600 E",
            "city": "SPANISH FORK",
            "state": "UT",
            "postal_code": "846601306",
            "telephone_number": "801-465-4896",
            "fax_number": "801-465-3267"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HENDERSON",
        "first_name": "STACIE",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-05-11",
        "last_updated": "2023-03-09",
        "certification_date": "2023-03-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "UT",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "UT",
            "license": "13182462-1206",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "STACIE",
            "last_name": "HENDERSON",
            "middle_name": "RENE DE JESUS",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Marissa Nicole Hiatt, FNP-C

• Physician Assistant in Spanish Fork, UT
• Providers in Spanish Fork, UT by specialty
• Physician Assistant in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 9, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.