Provider Demographics
NPI:1295476687
Name:STEVENS, KEITH MARSHALL III
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MARSHALL
Last Name:STEVENS
Suffix:III
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CANDY LN
Mailing Address - Street 2:
Mailing Address - City:BELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25015-1100
Mailing Address - Country:US
Mailing Address - Phone:304-545-8662
Mailing Address - Fax:
Practice Address - Street 1:20 CANDY LN
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:WV
Practice Address - Zip Code:25015-1100
Practice Address - Country:US
Practice Address - Phone:304-545-8662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103437367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered