Healthcare Provider Details

I. General information

NPI: 1740443779
Provider Name (Legal Business Name): DE'QUINCEY O STEWART P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 W BELVEDERE AVE SUITE 42
BALTIMORE MD
21215-5224
US

IV. Provider business mailing address

2401 W BELVEDERE AVE CREDENTIALING
BALTIMORE MD
21215-5216
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-5547
  • Fax: 410-601-5835
Mailing address:
  • Phone: 410-601-5523
  • Fax: 410-601-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0003070
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: