Healthcare Provider Details

I. General information

NPI: 1972457539
Provider Name (Legal Business Name): STOCKTON WISE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 NE CAVITT RD
CAMAS WA
98607-9759
US

IV. Provider business mailing address

3810 NE CAVITT RD
CAMAS WA
98607-9759
US

V. Phone/Fax

Practice location:
  • Phone: 360-521-6272
  • Fax:
Mailing address:
  • Phone: 360-521-6272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: