Provider Demographics
NPI:1790471134
Name:STULL, ALEXANDER JORDAN TY
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JORDAN TY
Last Name:STULL
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 1:4930 NAPLES ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3820
Mailing Address - Country:US
Mailing Address - Phone:619-276-1176
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3505
Practice Address - Country:US
Practice Address - Phone:619-381-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist