Provider Demographics
NPI:1275044166
Name:STOVER, ADAM T
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:T
Last Name:STOVER
Suffix:
Gender:M
Credentials:
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 555534
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5534
Mailing Address - Country:US
Mailing Address - Phone:760-725-1054
Mailing Address - Fax:
Practice Address - Street 1:5TH BATTALION 11TH MARINES
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E3456826146N00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic