Provider Demographics
NPI:1487306437
Name:ABT, STEVAN PAUL
Entity type:Individual
Prefix:MR
First Name:STEVAN
Middle Name:PAUL
Last Name:ABT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PALATINE APT 453
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-0609
Mailing Address - Country:US
Mailing Address - Phone:310-749-9112
Mailing Address - Fax:
Practice Address - Street 1:6640 ALTON PKWY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3734
Practice Address - Country:US
Practice Address - Phone:949-932-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001669367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered