Provider Demographics
NPI:1861795429
Name:STEVENS, TREVOR KENNETH (IDMT)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:KENNETH
Last Name:STEVENS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1625
Mailing Address - Country:US
Mailing Address - Phone:661-839-7559
Mailing Address - Fax:
Practice Address - Street 1:117 KANSAS ST
Practice Address - Street 2:
Practice Address - City:TRAVIS
Practice Address - State:CA
Practice Address - Zip Code:94535
Practice Address - Country:US
Practice Address - Phone:661-839-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians