Basic Information
| Provider Information | |||||||||
| NPI: | 1962578328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 STRATTON RD | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028552027 | ||||||||
| FaxNumber: | 8028552053 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 STRATTON RD | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027733386 | ||||||||
| FaxNumber: | 8027734578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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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 | 363A00000X | 055-0030797 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000324 | 05 | VT | MEDICAID |