Provider Demographics
NPI:1689209959
Name:STOCKTON, ETHAN TERRY (DPT)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:TERRY
Last Name:STOCKTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 ROSETTE DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5280
Mailing Address - Country:US
Mailing Address - Phone:505-206-1148
Mailing Address - Fax:
Practice Address - Street 1:7520 ROSETTE DR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-5280
Practice Address - Country:US
Practice Address - Phone:505-206-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty