MEDICARE: SANDRA ROSE STUART PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1689330862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA ROSE STUART PA-C

Provider Business Mailing Address
First Line	:	2920 TELEGRAPH AVE STE 100
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-2031
Country	:	US
Telephone Number	:	415-549-0212
Fax Number	:

Provider Business Practice Location Address
First Line	:	3032 WILSHIRE BLVD STE A
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-2370
Country	:	US
Telephone Number	:	310-971-9957
Fax Number	:	888-972-1912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2021
Last Update Date	:	09/05/2023

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