1093202053 NPI number — MR. WILSON PERSHING STEVENSON III

Table of content: MR. WILSON PERSHING STEVENSON III (NPI 1093202053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093202053 NPI number — MR. WILSON PERSHING STEVENSON III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENSON
Provider First Name:
WILSON
Provider Middle Name:
PERSHING
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093202053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3250 PORT OF BENTON BLVD STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99354-1670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-371-2570
Provider Business Mailing Address Fax Number:
866-880-2576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3250 PORT OF BENTON BLVD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99354-1670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-371-2570
Provider Business Practice Location Address Fax Number:
866-880-2576
Provider Enumeration Date:
04/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  601942637 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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