Provider Demographics
NPI:1609424175
Name:STEPHENS, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:STEPHENS
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 1:5228 GLIDE DR
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4423
Mailing Address - Country:US
Mailing Address - Phone:806-407-7007
Mailing Address - Fax:
Practice Address - Street 1:DGMC
Practice Address - Street 2:101 BODIN CIR
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-523-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program