Healthcare Provider Details

I. General information

NPI: 1427797604
Provider Name (Legal Business Name): CARLY RENAE STOCKMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WILMOT RD
TUCSON AZ
85711-2602
US

IV. Provider business mailing address

10615 W LARKHILL DR
MARANA AZ
85653-1327
US

V. Phone/Fax

Practice location:
  • Phone: 520-873-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9354
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number9354
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: