Basic Information
| Provider Information | |||||||||
| NPI: | 1053567826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 13439 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1053567826 | 05 | VA | MEDICAID | 1053567826 | 05 | NC | MEDICAID | 7100117150 | 05 | KY | MEDICAID | 1507311 | 05 | TN | MEDICAID |