Provider Demographics
NPI:1114535077
Name:STEPHENS, JONATHAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 PINE CIR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1638
Mailing Address - Country:US
Mailing Address - Phone:912-270-5676
Mailing Address - Fax:
Practice Address - Street 1:121 EVERETT RD STE 100
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1447
Practice Address - Country:US
Practice Address - Phone:518-489-2663
Practice Address - Fax:518-689-6106
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025354363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025354OtherNYS LICENSE