Provider Demographics
NPI:1689767105
Name:STEVENS, ROBERT E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 N. VANTAGE DR.
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4984
Mailing Address - Country:US
Mailing Address - Phone:479-443-5100
Mailing Address - Fax:479-443-5117
Practice Address - Street 1:4375 N. VANTAGE DR.
Practice Address - Street 2:SUITE 305
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4984
Practice Address - Country:US
Practice Address - Phone:479-443-5100
Practice Address - Fax:479-443-5117
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR51888P064Medicare ID - Type Unspecified