Provider Demographics
NPI:1700205291
Name:STEWART, AMANDA ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELIZABETH
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:17183 INTERSTATE 45 S STE 110
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3313
Mailing Address - Country:US
Mailing Address - Phone:936-270-3413
Mailing Address - Fax:936-270-3414
Practice Address - Street 1:17183 INTERSTATE 45 S STE 110
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3313
Practice Address - Country:US
Practice Address - Phone:936-270-3413
Practice Address - Fax:936-270-3414
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09007363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA09007OtherTEXAS LICENSE NUMBER