Healthcare Provider Details

I. General information

NPI: 1376042879
Provider Name (Legal Business Name): GREGORY D. STEWART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122-4379
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 NumberPA0002153
License Number StateWA

VIII. Authorized Official

Name: GREGORY D STEWART
Title or Position: CO-OWNER
Credential: PA
Phone: 206-948-4671