Provider Demographics
NPI:1275236655
Name:STEWART, ANTWAN
Entity Type:Individual
Prefix:
First Name:ANTWAN
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 GRAND AVE APT 22A3
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3127
Mailing Address - Country:US
Mailing Address - Phone:516-445-0690
Mailing Address - Fax:
Practice Address - Street 1:2363 GRAND AVE APT 22A3
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3127
Practice Address - Country:US
Practice Address - Phone:516-445-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver