Basic Information
| Provider Information | |||||||||
| NPI: | 1205880440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOVALL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEPHAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440246 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
| FaxNumber: | 6156202323 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 OAK ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385701728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9318235611 | ||||||||
| FaxNumber: | 6156202320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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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 | 367500000X | APN11058 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN131795 | TN | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 4179675 | 01 | TN | BLUE CROSS/BLUE SHIELD OF TN | OTHER |