Provider Demographics
NPI:1548236409
Name:STEVENSON, FLETCHER M (CRNA)
Entity Type:Individual
Prefix:
First Name:FLETCHER
Middle Name:M
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 1:2900 1ST AVE
Mailing Address - Street 2:ST MARYS HOSPTAL ROOM 6019
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1241
Mailing Address - Country:US
Mailing Address - Phone:304-399-0137
Mailing Address - Fax:304-399-0138
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:ST MARYS HOSPTAL ROOM 6019
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-399-0137
Practice Address - Fax:304-399-0138
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN10713367500000X
TNRN143453367500000X
GARN170816367500000X
WV69677367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV270052997003OtherTRICARE GROUP
OH2802800Medicaid
WV1071314OtherBRICKSTREET
WV3810008135Medicaid
TN4078445OtherBCBS
WV0207026000Medicaid
WV001706470OtherMSBCBS GROUP
OH2460484Medicaid
WV001945814OtherMSBCBS
WV27005299700OtherBRICKSTREET GROUP
TN3630211Medicaid
WV$$$$$$$$$00OtherOHIO WORKERS COMP
TN3630211Medicare PIN
WV8238262Medicare PIN
TN3630211Medicaid
OH2460484Medicaid