Provider Demographics
NPI:1962210542
Name:STOVER, CARSON DAVID PETRIE (LPN)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:DAVID PETRIE
Last Name:STOVER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-5221
Mailing Address - Country:US
Mailing Address - Phone:731-819-8830
Mailing Address - Fax:
Practice Address - Street 1:1000 N ARGONNE RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99212-2600
Practice Address - Country:US
Practice Address - Phone:509-534-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN96572164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse