Provider Demographics
NPI:1760934988
Name:PATRICK WAYNE STEWART
Entity Type:Organization
Organization Name:PATRICK WAYNE STEWART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICKWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:X
Authorized Official - Credentials:
Authorized Official - Phone:602-881-7023
Mailing Address - Street 1:1621 E JACINTO AVE
Mailing Address - Street 2:P.O. BOX 6895
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6895
Mailing Address - Country:US
Mailing Address - Phone:602-881-7023
Mailing Address - Fax:
Practice Address - Street 1:1621 E JACINTO AVE
Practice Address - Street 2:6895
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6895
Practice Address - Country:US
Practice Address - Phone:602-881-7023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATRICK WAYNE STEWART
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21090395251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD03746851OtherCUSTOMER