Provider Demographics
NPI:1679041297
Name:STOCKER, NATHANIEL CARL (APRN)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:CARL
Last Name:STOCKER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DOCTOR CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6502
Mailing Address - Country:US
Mailing Address - Phone:800-491-0909
Mailing Address - Fax:
Practice Address - Street 1:1730 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2820
Practice Address - Country:US
Practice Address - Phone:803-451-6133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22325363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5683Medicaid