Provider Demographics
NPI:1962455451
Name:BEVIS, STANLEY MARK (APN)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:MARK
Last Name:BEVIS
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1022
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-1022
Mailing Address - Country:US
Mailing Address - Phone:931-722-2369
Mailing Address - Fax:
Practice Address - Street 1:1600 US HIGHWAY 79 S
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75654
Practice Address - Country:US
Practice Address - Phone:903-717-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11551363LF0000X
TXAP145756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
3643099Medicare ID - Type Unspecified
Q68025Medicare UPIN