Basic Information
| Provider Information | |||||||||
| NPI: | 1427055086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435979 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 US HIGHWAY 395 N | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894105304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821695 | ||||||||
| FaxNumber: | 7757821558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 10544 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100505467 | 05 | NV | MEDICAID | 100506479 | 05 | NV | MEDICAID | XPY202245 | 05 | CA | MEDICAID |