Provider Demographics
NPI:1295822740
Name:STEWART, GREGORY DOUGLAS SR (PA, RN, CNOR, CRNFA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DOUGLAS
Last Name:STEWART
Suffix:SR
Gender:M
Credentials:PA, RN, CNOR, CRNFA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1542
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-7742
Mailing Address - Country:US
Mailing Address - Phone:206-948-4671
Mailing Address - Fax:425-513-9456
Practice Address - Street 1:2424 122ND ST SW
Practice Address - Street 2:B
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-4744
Practice Address - Country:US
Practice Address - Phone:206-948-4671
Practice Address - Fax:425-513-9456
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10002153363AS0400X
WA25800059197163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91 1403014OtherTIN