Provider Demographics
NPI:1275613960
Name:FARRELL, STEFAN BRICE (CNS, MSN)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:BRICE
Last Name:FARRELL
Suffix:
Gender:M
Credentials:CNS, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30361
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85275-0361
Mailing Address - Country:US
Mailing Address - Phone:480-844-9817
Mailing Address - Fax:480-461-9195
Practice Address - Street 1:2251 N 32ND ST LOT 16
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2426
Practice Address - Country:US
Practice Address - Phone:480-844-9817
Practice Address - Fax:480-461-9195
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN 085383163WR0006X, 364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ 0167830OtherBC/BS
AZ1Z4109OtherHEALTHNET
7562119OtherCIGNA
AZ479073Medicaid
890001034OtherRAILROAD
189762400OtherUS LABOR
7562119OtherCIGNA