Provider Demographics
NPI:1124017462
Name:STEVENS, KATHERINE S (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:S
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:190 E. BANNOCK
Mailing Address - Street 2:PED. HOSPITALIST
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-381-4509
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:PED. HOSPITALIST
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:208-381-4509
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6409208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000409Medicare PIN