Provider Demographics
NPI:1578510533
Name:STEPHENS, GARY BEN (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:BEN
Last Name:STEPHENS
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 1:11815 FORESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5414
Mailing Address - Country:US
Mailing Address - Phone:972-234-6600
Mailing Address - Fax:972-234-6575
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2220
Practice Address - Country:US
Practice Address - Phone:972-579-8100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32005367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBLUE CROSS-82822UOtherGARY STEPHENS, CRNA
TXAMERIGROUP-10031217OtherGARY STEPHENS, CRNA
TXS41041Medicare UPIN
TX8C0627Medicare ID - Type UnspecifiedGARY STEPHENS, CRNA
TXAMERIGROUP-10031217OtherGARY STEPHENS, CRNA