Healthcare Provider Details

I. General information

NPI: 1053909895
Provider Name (Legal Business Name): EVAN STOLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 RESERVOIR AVE STE 203
CRANSTON RI
02920-6032
US

IV. Provider business mailing address

1301 RICHMOND AVE
HOUSTON TX
77006-5451
US

V. Phone/Fax

Practice location:
  • Phone: 401-259-0340
  • Fax: 401-213-8538
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1167869
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01584
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPA01584
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: