Provider Demographics
NPI:1700980216
Name:STEPHENSON, JOHN ROBERT (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:STEPHENSON
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 1:1 SAINT MARY PL
Mailing Address - Street 2:PFS-PROF BILLING
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4343
Mailing Address - Country:US
Mailing Address - Phone:318-681-6878
Mailing Address - Fax:318-681-6753
Practice Address - Street 1:1 SAINT MARY PL
Practice Address - Street 2:PFS-PROF BILLING
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4343
Practice Address - Country:US
Practice Address - Phone:318-681-6878
Practice Address - Fax:318-681-6753
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN042421367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1960446Medicaid
LA59918Medicare ID - Type UnspecifiedMCARE PROV ID