Provider Demographics
NPI:1154491074
Name:STEWART, DEINA INMAN (PAC)
Entity Type:Individual
Prefix:MS
First Name:DEINA
Middle Name:INMAN
Last Name:STEWART
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 S. GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740
Mailing Address - Country:US
Mailing Address - Phone:626-857-2850
Mailing Address - Fax:
Practice Address - Street 1:1017 S FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2621
Practice Address - Country:US
Practice Address - Phone:626-404-6200
Practice Address - Fax:626-403-2580
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21425363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27703Medicare ID - Type Unspecified