Provider Demographics
NPI:1922293778
Name:STEWART, MARY WHITNEY A (PAA)
Entity Type:Individual
Prefix:
First Name:MARY WHITNEY
Middle Name:A
Last Name:STEWART
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:MARY WHITNEY
Other - Middle Name:ADAMS
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:678-514-1991
Practice Address - Fax:678-514-1992
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005179367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA704254055AMedicaid
GA202I323610Medicare PIN