Provider Demographics
NPI:1023309465
Name:STEWART, SAMUEL MICHAEL (PTA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:MICHAEL
Last Name:STEWART
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 MITCHEM RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3090
Mailing Address - Country:US
Mailing Address - Phone:704-830-4296
Mailing Address - Fax:704-824-2939
Practice Address - Street 1:1351 ROBINWOOD RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1693
Practice Address - Country:US
Practice Address - Phone:704-867-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2040225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant