Provider Demographics
NPI:1548294440
Name:STEWART, CHARLES DOUGLAS (PA C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:STEWART
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:C.
Other - Middle Name:DOUGLAS
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA C
Mailing Address - Street 1:111 BEECHWOOD EST
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 BEECHWOOD EST
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9723
Practice Address - Country:US
Practice Address - Phone:304-347-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00071363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0060671000Medicaid
WVP00999250OtherRAILROAD MEDICARE
WV0011253000OtherMEDICAID
WV0011253000OtherMEDICAID
WV0011253000OtherMEDICAID
WVWV5335AMedicare PIN