Healthcare Provider Details

I. General information

NPI: 1568611077
Provider Name (Legal Business Name): JEREMIAH W STEWART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

IV. Provider business mailing address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-1950
  • Fax:
Mailing address:
  • Phone: 260-969-1950
  • Fax: 260-918-2137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10001038A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: