Provider Demographics
NPI:1760404248
Name:STEWART, SCOTT LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LEE
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 1:1812 DISCOVERY LOOP
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2917
Mailing Address - Country:US
Mailing Address - Phone:423-747-7779
Mailing Address - Fax:
Practice Address - Street 1:1812 DISCOVERY LOOP
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2917
Practice Address - Country:US
Practice Address - Phone:423-747-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC204727163W00000X
TN054077367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052087Medicaid
NC8052087Medicaid