Provider Demographics
NPI:1881673085
Name:STEVENS, DOUGLAS S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:S
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12701 W 143RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-7715
Mailing Address - Country:US
Mailing Address - Phone:877-694-7722
Mailing Address - Fax:815-531-0055
Practice Address - Street 1:12701 W 143RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-7715
Practice Address - Country:US
Practice Address - Phone:877-694-7722
Practice Address - Fax:815-531-0055
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085001302363A00000X
ILIL085-001302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001302OtherSTATE LICENSE NUMBER