Provider Demographics
NPI:1528039807
Name:STEPHENS, ANGELA D (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PA
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 16626
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6626
Mailing Address - Country:US
Mailing Address - Phone:806-797-2139
Mailing Address - Fax:806-797-3105
Practice Address - Street 1:5902 66TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3048
Practice Address - Country:US
Practice Address - Phone:806-797-2139
Practice Address - Fax:806-797-3105
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D1830Medicare PIN