Provider Demographics
NPI:1003984634
Name:STEPHENSON, CHARLES NEVIN (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:NEVIN
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 HIGHWAY 206
Mailing Address - Street 2:
Mailing Address - City:CISCO
Mailing Address - State:TX
Mailing Address - Zip Code:76437-6447
Mailing Address - Country:US
Mailing Address - Phone:254-442-1441
Mailing Address - Fax:254-442-1466
Practice Address - Street 1:1619 HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:CISCO
Practice Address - State:TX
Practice Address - Zip Code:76437-6447
Practice Address - Country:US
Practice Address - Phone:254-442-1441
Practice Address - Fax:254-442-1466
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA00390OtherPA NUMBER
TX82N484Medicare ID - Type Unspecified
TXS75659Medicare UPIN