Healthcare Provider Details

I. General information

NPI: 1023309465
Provider Name (Legal Business Name): SAMUEL MICHAEL STEWART P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 ROBINWOOD RD
GASTONIA NC
28054-1693
US

IV. Provider business mailing address

3711 MITCHEM RD
GASTONIA NC
28054-3090
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-2319
  • Fax:
Mailing address:
  • Phone: 704-830-4296
  • Fax: 704-824-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2040
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: