Healthcare Provider Details

I. General information

NPI: 1760561856
Provider Name (Legal Business Name): JON STOCK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 17TH AVE N
FARGO ND
58102-2226
US

IV. Provider business mailing address

901 33RD AVE. N. APT. 108
FARGO ND
58102-0910
US

V. Phone/Fax

Practice location:
  • Phone: 701-446-2447
  • Fax:
Mailing address:
  • Phone: 701-526-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number278-04
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: