Provider Demographics
NPI:1780222190
Name:STEPHENSON, JOSHUA CARL
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:CARL
Last Name:STEPHENSON
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 1:616 W COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-1631
Mailing Address - Country:US
Mailing Address - Phone:208-405-3763
Mailing Address - Fax:
Practice Address - Street 1:30 MAPLE DR
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-1566
Practice Address - Country:US
Practice Address - Phone:208-405-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider