Healthcare Provider Details

I. General information

NPI: 1447180047
Provider Name (Legal Business Name): EZEKIEL TRUMAN CORNWELL STONE FP-C, CCP-C, TP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 DOVETAIL DR
HORSESHOE BEND ID
83629-5125
US

IV. Provider business mailing address

157 DOVETAIL DR
HORSESHOE BEND ID
83629-5125
US

V. Phone/Fax

Practice location:
  • Phone: 503-999-7583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: