Healthcare Provider Details

I. General information

NPI: 1326043365
Provider Name (Legal Business Name): MICHAEL SHAWN STOCKMAN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 KOONCE RD
HARPERS FERRY WV
25425-3126
US

IV. Provider business mailing address

5408 BARTONSVILLE RD
FREDERICK MD
21704-6802
US

V. Phone/Fax

Practice location:
  • Phone: 304-724-5918
  • Fax: 304-724-5920
Mailing address:
  • Phone: 301-694-0715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR073180
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: