Healthcare Provider Details

I. General information

NPI: 1649169475
Provider Name (Legal Business Name): JOHNATHAN STEVENSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-526-7858
  • Fax:
Mailing address:
  • Phone: 501-526-7858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number150048
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number902231
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: