Provider Demographics
NPI:1962634154
Name:STOCK, MARK (NP-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STOCK
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5810 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2830
Mailing Address - Country:US
Mailing Address - Phone:612-235-6008
Mailing Address - Fax:612-235-6003
Practice Address - Street 1:5810 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2830
Practice Address - Country:US
Practice Address - Phone:612-235-6008
Practice Address - Fax:612-235-6003
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 163073-8363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily