Provider Demographics
NPI:1568222909
Name:STOCKWELL, CHRISTIAN MARK
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:MARK
Last Name:STOCKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 COUGAR PL
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-1340
Mailing Address - Country:US
Mailing Address - Phone:510-362-9635
Mailing Address - Fax:
Practice Address - Street 1:2150 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2003
Practice Address - Country:US
Practice Address - Phone:209-656-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95029295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily