Provider Demographics
NPI:1780722892
Name:FEWELL, STEPHEN DANA (PA-C)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DANA
Last Name:FEWELL
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 1:4703 PACIFIC HWY E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98424
Mailing Address - Country:US
Mailing Address - Phone:253-922-9570
Mailing Address - Fax:253-922-9587
Practice Address - Street 1:4703 PACIFIC HWY E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98424-2620
Practice Address - Country:US
Practice Address - Phone:253-922-9570
Practice Address - Fax:253-922-9587
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA127506OtherL & I PIN