Provider Demographics
NPI:1568767093
Name:STOCKWELL, BRENTON A (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:A
Last Name:STOCKWELL
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 1:3650 PIPER STREET, STE A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-222-4624
Mailing Address - Fax:907-222-4651
Practice Address - Street 1:3650 PIPER STREET, STE A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-222-4624
Practice Address - Fax:907-222-4651
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6036363A00000X
AK120081363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant