Provider Demographics
NPI:1336262021
Name:STEWART, FREDERICK E (PA-C)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:E
Last Name:STEWART
Suffix:
Gender:M
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 1:7955 SPYGLASS HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8249
Mailing Address - Country:US
Mailing Address - Phone:321-255-6670
Mailing Address - Fax:321-242-2545
Practice Address - Street 1:7955 SPYGLASS HILL RD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8249
Practice Address - Country:US
Practice Address - Phone:321-255-6670
Practice Address - Fax:321-242-2545
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9108629OtherFL PA LICENSE
FLPA9103271OtherFL LICENSE