Healthcare Provider Details

I. General information

NPI: 1194840520
Provider Name (Legal Business Name): STEWART CRAIG SHIVELY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: S CRAIG SHIVELY

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COLBY AVE
EVERETT WA
98201-1665
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 425-261-2000
  • Fax:
Mailing address:
  • Phone: 866-366-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003914
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10003914
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: