Healthcare Provider Details

I. General information

NPI: 1790105187
Provider Name (Legal Business Name): PAUL STUART V
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 04/19/2025
Certification Date: 04/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 TOMALES RD
PETALUMA CA
94952-5002
US

IV. Provider business mailing address

4000 COAST GUARD BLVD
PORTSMOUTH VA
23703-2135
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: