Basic Information
| Provider Information | |||||||||
| NPI: | 1609473297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | FIFTH THIRD BANK BLDG, 5TH FL | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178804121 | ||||||||
| FaxNumber: | 3178800343 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 N ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462183318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175545200 | ||||||||
| FaxNumber: | 3175545247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2020 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 28203770A | IN | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | 71011246A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.