Healthcare Provider Details

I. General information

NPI: 1871116913
Provider Name (Legal Business Name): STEW ELLINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2020
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 NE WYATT CT STE 101
BEND OR
97701-7679
US

IV. Provider business mailing address

2115 NE WYATT CT STE 101
BEND OR
97701-7679
US

V. Phone/Fax

Practice location:
  • Phone: 541-205-7457
  • Fax:
Mailing address:
  • Phone: 541-205-7457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA223676
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: