Healthcare Provider Details

I. General information

NPI: 1134455298
Provider Name (Legal Business Name): MICHAEL LEE STEVELEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MICHIGAN AVE
LOGANSPORT IN
46947-1528
US

IV. Provider business mailing address

1101 MICHIGAN AVE
LOGANSPORT IN
46947-1528
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-2663
  • Fax: 574-753-1729
Mailing address:
  • Phone: 574-722-2663
  • Fax: 574-753-1729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-003732
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001746A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: