Provider Demographics
NPI:1811660715
Name:STEVENS, MARK A
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 BRAVO ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25306
Mailing Address - Country:US
Mailing Address - Phone:304-444-9395
Mailing Address - Fax:
Practice Address - Street 1:327 BRAVO ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25306
Practice Address - Country:US
Practice Address - Phone:304-444-9395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant