Provider Demographics
NPI:1114964780
Name:STEPHENS, CLYDE RICHARD (PAC)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:RICHARD
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 OLD HIGHWAY 11 E
Mailing Address - Street 2:
Mailing Address - City:GREENBUSH
Mailing Address - State:MN
Mailing Address - Zip Code:56726-4128
Mailing Address - Country:US
Mailing Address - Phone:218-782-2881
Mailing Address - Fax:
Practice Address - Street 1:711 DELMORE DR
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1534
Practice Address - Country:US
Practice Address - Phone:218-463-1365
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P11279Medicare UPIN