Healthcare Provider Details

I. General information

NPI: 1295822740
Provider Name (Legal Business Name): GREGORY DOUGLAS STEWART SR. PA, RN, CNOR, CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 122ND ST SW B
EVERETT WA
98204-4744
US

IV. Provider business mailing address

PO BOX 1542
MUKILTEO WA
98275-7742
US

V. Phone/Fax

Practice location:
  • Phone: 206-948-4671
  • Fax: 425-513-9456
Mailing address:
  • Phone: 206-948-4671
  • Fax: 425-513-9456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10002153
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number25800059197
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: