Provider Demographics
NPI:1366501090
Name:STETKEVICH, ROMAN (PA)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:STETKEVICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 ORO BLANCO AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8208
Mailing Address - Country:US
Mailing Address - Phone:909-238-6489
Mailing Address - Fax:
Practice Address - Street 1:58471 29 PALMS HWY STE 302
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5818
Practice Address - Country:US
Practice Address - Phone:442-205-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant