MEDICARE: AMY JAYNE STEVENS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	85001889	IL
2	363A00000X	Physician Assistant	85001889	IL

General Provider Information

NPI Number	:	1982699955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY JAYNE STEVENS PA-C

Provider Business Mailing Address
First Line	:	2 CARLSON PKWY N
Second Line	:	STE 240
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-4485
Country	:	US
Telephone Number	:	618-327-8486
Fax Number	:	618-327-8523

Provider Business Practice Location Address
First Line	:	267 E SAINT LOUIS ST
Second Line	:
City	:	NASHVILLE
State	:	IL
Zip	:	62263-1702
Country	:	US
Telephone Number	:	618-244-0031
Fax Number	:	952-473-7281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	03/01/2024

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