Provider Demographics
NPI:1053909895
Name:STOLER, EVAN (PA)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:STOLER
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 1:1301 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-5451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 RESERVOIR AVE STE 203
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6032
Practice Address - Country:US
Practice Address - Phone:401-259-0340
Practice Address - Fax:401-213-8538
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01584101YM0800X, 363A00000X
NE1167869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health