Provider Demographics
NPI:1376623215
Name:STOCK, DEBRA M (PA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:M
Last Name:STOCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2290 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2929
Mailing Address - Country:US
Mailing Address - Phone:707-643-5785
Mailing Address - Fax:707-643-5876
Practice Address - Street 1:480 CHADBOURNE RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-9639
Practice Address - Country:US
Practice Address - Phone:707-399-4500
Practice Address - Fax:707-399-9419
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CAPA16490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16490Medicaid
CAPA16490Medicaid
CAZZZ97788ZMedicare PIN