Provider Demographics
NPI:1255797304
Name:STOCKTON, NICOLE ALYSE (LSA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ALYSE
Last Name:STOCKTON
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 CARTAGENA DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-3923
Mailing Address - Country:US
Mailing Address - Phone:361-793-9044
Mailing Address - Fax:
Practice Address - Street 1:3418 CARTAGENA DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-3923
Practice Address - Country:US
Practice Address - Phone:361-793-9044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00646363AS0400X, 246ZC0007X
TX163880246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX671743OtherTEXAS MEDICAL BOARD - LSA
TXSA00646OtherTEXAS MEDICAL BOARD - LSA
TX163880OtherTHE NATIONAL BOARD OF ST & SA
TXSA00646OtherTEXAS MEDICAL BOARD - LSA
TX8HW445OtherBCBS - XCITE SURGICAL
TX8HW446OtherBCBS - UNIVERSAL SURGICAL PARTNERS