Healthcare Provider Details

I. General information

NPI: 1063411098
Provider Name (Legal Business Name): CHRISTOPHER C STEPHENSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

IV. Provider business mailing address

5633 RELIABLE PKWY
CHICAGO IL
60686-0056
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-1950
  • Fax:
Mailing address:
  • Phone: 260-969-1950
  • Fax: 260-918-2137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000433A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: