Provider Demographics
NPI:1962686022
Name:STICKWAN, MARVIN J (RN)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:J
Last Name:STICKWAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 CHIEF RICHARD CARL SR. DRIVE
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:AK
Mailing Address - Zip Code:99921
Mailing Address - Country:US
Mailing Address - Phone:907-826-2628
Mailing Address - Fax:
Practice Address - Street 1:7300 KLAWOCK-HOLLIS HWY.
Practice Address - Street 2:
Practice Address - City:KLAWOCK
Practice Address - State:AK
Practice Address - Zip Code:99925
Practice Address - Country:US
Practice Address - Phone:907-755-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK27807163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse