Healthcare Provider Details

I. General information

NPI: 1871744425
Provider Name (Legal Business Name): PHILLIP E STEVENSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 NE 10TH AVE
PAYETTE ID
83661-5420
US

IV. Provider business mailing address

1441 NE 10TH AVE
PAYETTE ID
83661-5420
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9376
  • Fax: 208-642-9598
Mailing address:
  • Phone: 208-642-9376
  • Fax: 208-642-9598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPENDING
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: