Provider Demographics
NPI:1194840520
Name:SHIVELY, STEWART CRAIG (PA-C)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:CRAIG
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:S
Other - Middle Name:CRAIG
Other - Last Name:SHIVELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8344368Medicaid
WAGAB14090Medicare PIN
WAP01014Medicare UPIN