Healthcare Provider Details

I. General information

NPI: 1104345263
Provider Name (Legal Business Name): NATHANAEL CHRISTOPHER STUCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CENTER ST STE 2S
MOBILE AL
36604-1541
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-5108
  • Fax: 251-660-5792
Mailing address:
  • Phone: 251-434-3626
  • Fax: 251-445-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1271
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: