Provider Demographics
NPI:1609170877
Name:STEWART, RICHARD REAGAN
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:REAGAN
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 1:3507 TANELORN DR APT 1726
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-8983
Mailing Address - Country:US
Mailing Address - Phone:631-833-8446
Mailing Address - Fax:
Practice Address - Street 1:3507 TANELORN DR APT 1726
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-8983
Practice Address - Country:US
Practice Address - Phone:631-833-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274519164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse