Provider Demographics
NPI:1710160106
Name:TAVENER, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TAVENER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 N ALMA SCHOOL RD
Mailing Address - Street 2:STE 160
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5901
Mailing Address - Country:US
Mailing Address - Phone:480-963-1853
Mailing Address - Fax:480-963-1854
Practice Address - Street 1:1250 S CLEARVIEW AVE
Practice Address - Street 2:100
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3378
Practice Address - Country:US
Practice Address - Phone:480-423-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-09
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5115363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5115OtherARIZONA LICENSE
AZ5115OtherARIZONA LICENSE