Provider Demographics
NPI:1639174519
Name:DEPORTER, STEPHEN P (APN)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:P
Last Name:DEPORTER
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 E RUSHOLME ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2459
Mailing Address - Country:US
Mailing Address - Phone:563-421-7681
Mailing Address - Fax:
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2459
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-081354363LF0000X
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
056857OtherHEALTH ALLIANCE
185922OtherIOWA HEALTH SOLUTIONS
IL01G2OtherJOHN DEERE HEALTH PLAN
4796890020OtherDMERC
ILL95017Medicare PIN
056857OtherHEALTH ALLIANCE