Provider Demographics
NPI:1417056862
Name:BROWN, STANTON HERRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:STANTON
Middle Name:HERRICK
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA-C
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 1028
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93656-1028
Mailing Address - Country:US
Mailing Address - Phone:559-867-7200
Mailing Address - Fax:559-867-0152
Practice Address - Street 1:3567 MT. WHITNEY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:CA
Practice Address - Zip Code:93656-1028
Practice Address - Country:US
Practice Address - Phone:559-867-7200
Practice Address - Fax:559-867-0152
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11937363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA11937Medicaid
CAAX730YMedicare PIN