Provider Demographics
NPI:1417286683
Name:STEVENSON, JAMES EDWARD (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4421
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:701-234-2345
Practice Address - Street 1:737 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4421
Practice Address - Country:US
Practice Address - Phone:701-234-2119
Practice Address - Fax:701-234-2345
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR29410367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1417286683Medicaid
NDN714934Medicare PIN