Healthcare Provider Details

I. General information

NPI: 1336262021
Provider Name (Legal Business Name): FREDERICK E STEWART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7955 SPYGLASS HILL RD STE A
MELBOURNE FL
32940-8249
US

IV. Provider business mailing address

7955 SPYGLASS HILL RD STE A
MELBOURNE FL
32940-8249
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-6670
  • Fax: 321-242-2545
Mailing address:
  • Phone: 321-255-6670
  • Fax: 321-242-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108629
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: