Provider Demographics
NPI:1104128727
Name:DR PATRICE N STEVENSON
Entity type:Organization
Organization Name:DR PATRICE N STEVENSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:N
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-862-5138
Mailing Address - Street 1:4468 185TH AVE E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9112
Mailing Address - Country:US
Mailing Address - Phone:253-862-5138
Mailing Address - Fax:253-862-5138
Practice Address - Street 1:407 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3770
Practice Address - Country:US
Practice Address - Phone:253-862-5138
Practice Address - Fax:253-862-5138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022286208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1002229Medicaid
WA1340STOtherWA REGENCE
WA4079238OtherAETNA
WA0252586OtherWA L & I
WA1002229Medicaid