Healthcare Provider Details

I. General information

NPI: 1083698047
Provider Name (Legal Business Name): STEPHANIE B. EVANS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 STATE ST
SCHENECTADY NY
12307-1508
US

IV. Provider business mailing address

1044 STATE ST
SCHENECTADY NY
12307-1508
US

V. Phone/Fax

Practice location:
  • Phone: 518-370-1441
  • Fax: 518-395-9431
Mailing address:
  • Phone: 518-370-1441
  • Fax: 518-395-9431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number212905
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: