Healthcare Provider Details

I. General information

NPI: 1770765026
Provider Name (Legal Business Name): THOMAS BRYANT STEPHENS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 29TH ST STE 201
ASHLAND KY
41101-1932
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-420-0140
  • Fax: 606-420-0141
Mailing address:
  • Phone: 606-408-9565
  • Fax: 606-408-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA801
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: