Provider Demographics
NPI:1356676704
Name:STEWART, CHRISTIE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:NICOLE
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICKI
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:612 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2662
Mailing Address - Country:US
Mailing Address - Phone:217-224-9484
Mailing Address - Fax:217-224-7950
Practice Address - Street 1:612 N 11TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2662
Practice Address - Country:US
Practice Address - Phone:217-224-9484
Practice Address - Fax:217-224-7950
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1088886OtherNCCPA
IL208343013Medicare PIN
ILF400267250Medicare PIN