MEDICARE: MS. MYRA NICHOLE STEWART PT, DPT

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	225100000X	Physical Therapist	292321	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	292321	OTHER	CA	CALIFORNIA

General Provider Information

NPI Number	:	1912449869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MYRA NICHOLE STEWART PT, DPT

Provider Business Mailing Address
First Line	:	3810 LA CRESCENTA AVE
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-3914
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 LA CRESCENTA AVE
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-3914
Country	:	US
Telephone Number	:	818-369-7700
Fax Number	:

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

Provider Enumeration Date	:	11/09/2016
Last Update Date	:	09/21/2017

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