Provider Demographics
NPI:1265978373
Name:STEPHENSON, RICK ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:ANTHONY
Last Name:STEPHENSON
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 1:1 WILLOWWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44215-9642
Mailing Address - Country:US
Mailing Address - Phone:440-812-9245
Mailing Address - Fax:
Practice Address - Street 1:970 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6225
Practice Address - Country:US
Practice Address - Phone:740-382-9293
Practice Address - Fax:740-383-6091
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004952RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2257383Medicaid
H46295Medicare UPIN