Healthcare Provider Details

I. General information

NPI: 1114903168
Provider Name (Legal Business Name): MARY LOU STEVENS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WELLINGTON AVE
GRAND JUNCTION CO
81501-6132
US

IV. Provider business mailing address

PO BOX 62
GRAND JUNCTION CO
81502-0062
US

V. Phone/Fax

Practice location:
  • Phone: 970-244-2457
  • Fax: 970-255-1809
Mailing address:
  • Phone: 970-244-7050
  • Fax: 970-255-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2119
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: