Provider Demographics
NPI:1225479686
Name:STANCO, JOSEPH LAWRENCE JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:LAWRENCE
Last Name:STANCO
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2348 TRIDENT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-5508
Mailing Address - Country:US
Mailing Address - Phone:336-831-4209
Mailing Address - Fax:
Practice Address - Street 1:2348 TRIDENT WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5508
Practice Address - Country:US
Practice Address - Phone:336-831-4209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman