Provider Demographics
NPI:1326043365
Name:STOCKMAN, MICHAEL SHAWN (CRNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:STOCKMAN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5408 BARTONSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-6802
Mailing Address - Country:US
Mailing Address - Phone:301-694-0715
Mailing Address - Fax:
Practice Address - Street 1:440 KOONCE RD
Practice Address - Street 2:
Practice Address - City:HARPERS FERRY
Practice Address - State:WV
Practice Address - Zip Code:25425-3126
Practice Address - Country:US
Practice Address - Phone:304-724-5918
Practice Address - Fax:304-724-5920
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR073180363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00748732Medicaid