Provider Demographics
NPI:1154709749
Name:STEVENSON, PAUL
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 EL PASEO
Mailing Address - Street 2:SUITE F
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:575-524-2666
Mailing Address - Fax:575-524-4328
Practice Address - Street 1:1300 EL PASEO RD
Practice Address - Street 2:SUITE F
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-6024
Practice Address - Country:US
Practice Address - Phone:575-524-2666
Practice Address - Fax:575-524-4328
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMABOC 11818156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1437254992Medicare PIN
NM0183680001Medicare UPIN