Provider Demographics
NPI:1063411098
Name:STEPHENSON, CHRISTOPHER C (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:C
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5633 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0056
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-918-2137
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:260-969-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000433A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000340097OtherBLUE CROSS/BLUE SHIELD
INP00180423OtherRAILROAD MEDICARE
IN000000340097OtherBLUE CROSS/BLUE SHIELD
IN203170UUMedicare PIN
INP00180423OtherRAILROAD MEDICARE