Provider Demographics
NPI:1124829007
Name:STEVONS, AVERY
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:STEVONS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 APPLING DR UNIT 310
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4789
Mailing Address - Country:US
Mailing Address - Phone:517-614-7513
Mailing Address - Fax:
Practice Address - Street 1:1483 TOBIAS GADSON BLVD STE 208
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4796
Practice Address - Country:US
Practice Address - Phone:843-609-2309
Practice Address - Fax:843-727-8240
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant