Provider Demographics
NPI:1871744425
Name:STEVENSON, PHILLIP E (PA-C)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:E
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:1441 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-5420
Practice Address - Country:US
Practice Address - Phone:208-642-9376
Practice Address - Fax:208-642-9598
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808211700Medicaid
ID808211701Medicaid
ID808211702Medicaid
ID012345OtherLICENSE PENDING