Provider Demographics
NPI:1972577054
Name:STEVENSON, SCOTT (PA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-8567
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-8567
Mailing Address - Country:US
Mailing Address - Phone:609-815-7810
Mailing Address - Fax:609-815-7814
Practice Address - Street 1:1 CAPITAL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2520
Practice Address - Country:US
Practice Address - Phone:302-733-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000225363AS0400X
NJ25MP00276900363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEP74519Medicare UPIN
DE010737C63Medicare PIN
NJ236423Medicare PIN