Provider Demographics
NPI:1205880440
Name:STOVALL, MICHAEL STEPHAN (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHAN
Last Name:STOVALL
Suffix:
Gender:M
Credentials:CRNA
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 440246
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0246
Mailing Address - Country:US
Mailing Address - Phone:615-620-2320
Mailing Address - Fax:615-620-2323
Practice Address - Street 1:315 OAK ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1728
Practice Address - Country:US
Practice Address - Phone:931-823-5611
Practice Address - Fax:615-620-2320
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11058367500000X
TNRN131795163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4179675OtherBLUE CROSS/BLUE SHIELD OF TN
TN36349231Medicare PIN