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: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 UNIVERSITY PKWY STE 101B
PENSACOLA FL
32514-5485
US

IV. Provider business mailing address

PO BOX 95590
SOUTH JORDAN UT
84095-0590
US

V. Phone/Fax

Practice location:
  • Phone: 850-208-6150
  • Fax: 850-916-8700
Mailing address:
  • Phone: 801-784-0954
  • Fax: 801-352-7976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA91201517
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: