Provider Demographics
NPI:1780668103
Name:STEVENS, JOHN B (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SOUTH WEST STREET
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:4038 WEST RD
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1842
Practice Address - Country:US
Practice Address - Phone:607-758-3008
Practice Address - Fax:607-758-7032
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01295894Medicaid
NYCC7687Medicare PIN