Provider Demographics
NPI:1114447331
Name:STEVENSON, PHILIP (CAA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 BLUFF OAK WAY APT 6207
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-6132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2173 CENTERVILLE PL STE A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8303
Practice Address - Country:US
Practice Address - Phone:850-385-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA391367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty