Provider Demographics
NPI:1982699955
Name:STEVENS, AMY JAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JAYNE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 CARLSON PKWY N
Mailing Address - Street 2:STE 240
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:618-327-8486
Mailing Address - Fax:618-327-8523
Practice Address - Street 1:267 E SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1702
Practice Address - Country:US
Practice Address - Phone:618-244-0031
Practice Address - Fax:952-473-7281
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85001889207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT01207Medicare PIN
ILP75095Medicare UPIN
ILK24156Medicare PIN