Provider Demographics
NPI:1083854939
Name:STEVENS, AMANDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:304 S PARK LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5753
Mailing Address - Country:US
Mailing Address - Phone:580-379-6500
Mailing Address - Fax:580-379-6509
Practice Address - Street 1:304 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5753
Practice Address - Country:US
Practice Address - Phone:580-379-6500
Practice Address - Fax:580-379-6509
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2651363A00000X, 363A00000X
HIAMD-627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200656930AMedicaid
HI1083854939Medicaid
NVBS086ZMedicare PIN
HIBS086ZMedicare PIN