Provider Demographics
NPI:1316562457
Name:STEPHENSON, EVANS MICHAEL (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:EVANS
Middle Name:MICHAEL
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121A PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-2445
Mailing Address - Country:US
Mailing Address - Phone:919-498-5181
Mailing Address - Fax:
Practice Address - Street 1:280 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1838
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
NC0010-10988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program