Provider Demographics
NPI:1467472084
Name:STEVENS, GREGORY TODD
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:TODD
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9328 CRYSTAL BROOK DR
Mailing Address - Street 2:
Mailing Address - City:APISON
Mailing Address - State:TN
Mailing Address - Zip Code:37302-7571
Mailing Address - Country:US
Mailing Address - Phone:423-645-4480
Mailing Address - Fax:
Practice Address - Street 1:550 FORT LOUDOUN MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5673
Practice Address - Country:US
Practice Address - Phone:865-271-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002663363A00000X
TN755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S52148Medicare UPIN