Provider Demographics
NPI:1902833817
Name:STOUT, ALLEN E (DC, FNP)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:E
Last Name:STOUT
Suffix:
Gender:M
Credentials:DC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 HWY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426
Mailing Address - Country:US
Mailing Address - Phone:928-768-2811
Mailing Address - Fax:928-768-9787
Practice Address - Street 1:5130 HWY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426
Practice Address - Country:US
Practice Address - Phone:928-768-2811
Practice Address - Fax:928-768-9787
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11653363L00000X, 2081P2900X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP11653OtherNURSE PRACTITIONER
AZ7353OtherARIZONA LICENSE NUMER
NVU57834Medicare UPIN