Provider Demographics
NPI:1740879493
Name:STEVENS, SYDNEY P (PA-C)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:P
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:P
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3038
Mailing Address - Country:US
Mailing Address - Phone:618-398-8840
Mailing Address - Fax:618-398-8847
Practice Address - Street 1:7210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3038
Practice Address - Country:US
Practice Address - Phone:618-398-8840
Practice Address - Fax:618-398-8847
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085008912363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program