Provider Demographics
NPI:1346214202
Name:STOLL, DAVID (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:STOLL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10512 N 110TH EAST AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6636
Mailing Address - Country:US
Mailing Address - Phone:918-376-8959
Mailing Address - Fax:918-376-8999
Practice Address - Street 1:10512 N 110TH EAST AVE
Practice Address - Street 2:STE 220
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6636
Practice Address - Country:US
Practice Address - Phone:918-376-8959
Practice Address - Fax:918-376-8999
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00911363A00000X, 363AM0700X, 363AS0400X
OK2678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100643000AMedicaid
KS100643000EMedicaid
KS100643000AMedicaid
003917001Medicare PIN
KSP00653346Medicare PIN
042013Medicare ID - Type Unspecified