Provider Demographics
NPI:1598402877
Name:STEWART, HENRY LINCOLN
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:LINCOLN
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 1:4755 WELCOME AVE N APT 6
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3565
Mailing Address - Country:US
Mailing Address - Phone:126-725-9566
Mailing Address - Fax:
Practice Address - Street 1:4755 WELCOME AVE N APT 6
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3565
Practice Address - Country:US
Practice Address - Phone:126-725-9566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR558167902018172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver