Provider Demographics
NPI:1952692568
Name:STEVENSON, CAROLE ANNE BURG (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:ANNE BURG
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:ANNE
Other - Last Name:BURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 EDGEWATER PL
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1205
Mailing Address - Country:US
Mailing Address - Phone:281-451-8380
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:201-996-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00255100363A00000X
TXPA07801363A00000X
NY014811-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant