Provider Demographics
NPI:1295806412
Name:STEWART, DEBORAH L (PA-C)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 673671
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3671
Mailing Address - Country:US
Mailing Address - Phone:810-720-5715
Mailing Address - Fax:810-600-1597
Practice Address - Street 1:30671 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1635
Practice Address - Country:US
Practice Address - Phone:810-720-5715
Practice Address - Fax:810-600-1597
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004225363AM0700X
WI3987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35120033Medicare PIN