Provider Demographics
NPI:1922103530
Name:STEWART, R SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:SUSAN
Last Name:STEWART
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 LELARAY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2804
Mailing Address - Country:US
Mailing Address - Phone:719-632-7641
Mailing Address - Fax:
Practice Address - Street 1:2002 LELARAY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2804
Practice Address - Country:US
Practice Address - Phone:719-632-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO53226363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04838254Medicaid
P21226Medicare UPIN