Provider Demographics
NPI:1649232638
Name:JEWELL, STEPHEN M (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:JEWELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DEXTER CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3461
Mailing Address - Country:US
Mailing Address - Phone:563-344-6667
Mailing Address - Fax:563-344-6740
Practice Address - Street 1:1410 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2940
Practice Address - Country:US
Practice Address - Phone:563-244-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-108642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44321200Medicaid
IA0292268Medicaid
I9765Medicare PIN