Provider Demographics
NPI:1417201419
Name:STEVENS, TIMOTHY ROGER (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROGER
Last Name:STEVENS
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 1:1055 N 500 W ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1075 S HWY 89
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647
Practice Address - Country:US
Practice Address - Phone:435-462-2044
Practice Address - Fax:435-462-2043
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9144918-8906363AM0700X
UT9144918-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical