Healthcare Provider Details

I. General information

NPI: 1770919094
Provider Name (Legal Business Name): STEPHEN PAUL WARREN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 N BELAIR RD
EVANS GA
30809-3096
US

IV. Provider business mailing address

393 N BELAIR RD
EVANS GA
30809-3096
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-0104
  • Fax:
Mailing address:
  • Phone: 706-868-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN176765
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: