Provider Demographics
NPI:1407920739
Name:EZZELL, STANTON W (NP)
Entity Type:Individual
Prefix:
First Name:STANTON
Middle Name:W
Last Name:EZZELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5239
Mailing Address - Country:US
Mailing Address - Phone:252-635-5290
Mailing Address - Fax:252-633-9609
Practice Address - Street 1:703 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5239
Practice Address - Country:US
Practice Address - Phone:252-635-5290
Practice Address - Fax:252-633-9609
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300311363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC300311OtherNC MEDICAL LICENSE