Provider Demographics
NPI:1912786575
Name:STEVENSEN, ROSS
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:STEVENSEN
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 1:18 KELLOGG ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4376
Mailing Address - Country:US
Mailing Address - Phone:507-676-3770
Mailing Address - Fax:
Practice Address - Street 1:18 KELLOGG ST APT 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4376
Practice Address - Country:US
Practice Address - Phone:507-676-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program