Provider Demographics
NPI:1689815110
Name:STEWART, JERL DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:JERL
Middle Name:DAVID
Last Name:STEWART
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 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:606-330-6000
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1000 SAINT JOSEPH LANE
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8345
Practice Address - Country:US
Practice Address - Phone:606-330-6000
Practice Address - Fax:606-330-7825
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR82527367500000X
KY3006450367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177959001Medicaid
KY7100103680Medicaid
AR5V153Medicare PIN