=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376042879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY D. STEWART
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2018
-----------------------------------------------------
Last Update Date | 02/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 BROADWAY
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98122-4379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-948-4671
-----------------------------------------------------
Fax | 425-513-9456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1542
-----------------------------------------------------
City | MUKILTEO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98275-7742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-948-4671
-----------------------------------------------------
Fax | 425-513-9456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | GREGORY D STEWART
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 206-948-4671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA0002153
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------