Provider Demographics
NPI:1235105016
Name:STEWARD, IAN NICHOLS (NP)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:NICHOLS
Last Name:STEWARD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W PATERSON ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-2557
Mailing Address - Country:US
Mailing Address - Phone:269-349-2641
Mailing Address - Fax:269-488-0806
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2557
Practice Address - Country:US
Practice Address - Phone:269-349-2641
Practice Address - Fax:269-488-0806
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225561363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4841918-10Medicaid
MIG56008132Medicare PIN
MI4841918-10Medicaid