Provider Demographics
NPI:1245288158
Name:STEVENS, BRIAN S (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PA-C
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 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:440-960-0264
Practice Address - Street 1:3600 KOLBE RD
Practice Address - Street 2:SUITE 227
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1654
Practice Address - Country:US
Practice Address - Phone:440-960-3304
Practice Address - Fax:440-960-3482
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH002340363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OH2189859Medicaid
OH0236248Medicaid
OHPA26885Medicare PIN
OH3025372Medicaid
OH2189859Medicaid
OH9284951Medicare PIN