Provider Demographics
NPI:1801352067
Name:STEWART, STACEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1848
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:313-473-1605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant